CASE FORMAT

1. PRELIMINARY DATA

NAME

AGE

SEX

RELIGION

EDUCATION

OCCUPATION

MARITAL STATUS

ADDRESS

IPD/OPD NUMBER

DATE OF CASE TAKING

2. CHIEF COMPLAINT(S)

LOCATION SENSATION MODALITIES CONCOMITANT

SYSTEM OR PART OR AILMENTS FROM
ORGAN AFFECTED AGGRAVATION <
AMELIORATION >

3. HISTORY OF CHIEF COMPLAINT(S)

NEGATIVE HISTORY

4. PAST HISTORY

MEDICAL HISTORY

TREATMENT HISTORY

SURGICAL HISTORY

ALLERGIC HISTORY
5. FAMILY HISTORY

6. PERSONAL HISTORY

DIET

APPETITE

THIRST

BOWEL HABITS

BLADDER HABITS

CRAVING(s)

AVERSION(s)

SLEEP

DREAMS

PERSPIRATION

THERMALS

7.MENSTRUAL HISTORY (IF APPLICABLE)

MENARCHE

LMP

CYCLE- REGULAR/IRREGULAR, QUANTITY(PROFUSE/NORMAL/SCANTY), COLOR (BRIGHT RED/DARK

RED), ODOR, COMPLAINTS BEFORE /DURING /AFTER MENSES, CLOTS ETC

MENOPAUSE—

8.OBSTETRIC HISTORY

9.LIFE SPACE INVESTIGATION

10.GENERAL PHYSICAL EXAMINATION

BUILT AND NOURISHMENT

ORIENTATION WITH TIME PALCE AND PERSON

HEIGHT…………WEIGHT……… BMI……...

EYES……. NOSE……

ORAL HYGIENE-------- TONGUE………TEETH……...

SKIN AND NAILS

PALLOR, CYANOSIS, ICTERUS, CLUBBING, OEDEMA, AND LYMPADENOPATHY…….

VITAL SIGNS

BLOOD PRESSURE

TEMPERATURE

PULSE

RESPIRATORY RATE

11. SYSTEMIC EXAMINATION

RESPIRATORY

CARDIOVASCULAR

GASTROINTESTINAL

LOCOMOTOR

CENTRAL NERVOUS SYSTEM

12. INVESTIGATIONS

Done/required

13. PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

Provisional diagnosis Differential diagnosis

14. ANALYSIS AND EVALUATION OF CASE

15. MIASMATIC ANALYSIS

16. TOTALITY OF SYMPTOMS

17.REPERTORY SELECTION
18. REPERTORIAL TOTALITY

19. PRESCRIPTION

20. GENERAL MANAGEMENT

21. FOLLOW UP CRITERIA

 CASE TAKING

Your Case taking starts as soon as the patient takes an appointment on the telephone and or as
soon as he enters your cabin so the physician must be vigilant enough (§ 83) in his observation of
the patient for :

1. Way of entering (Timid/ Bold; Fast /Slow)

2. Expressions (Smiling/Serious/Anxious/Sad/Cheerful/Shy)
3. The way Patient Greets you and leaves the clinic.

Preliminary Data:-
Name:-
Age:- Sex:-
Occupation :- Status:-
Religion:- Mother tongue:-
Address :- Contact no:-

C/C:-
 Since when the complaints started
 Onset - was Sudden or Gradual
 Duration of the pain ,how long pain remains, how the pain comes and
goes,character of pain,extension of pain.
 Which side first the complaint started Right or Left or it was from left to right
or right to left.
 Is there any Cross wise affections e.g. Pain or any pathology in Upper left extremity
and Lower right Extremity only. Etc.
 Modalities regarding the c/c.
 Any investigations done for c/c.
In many Cases after noting the C/C the physician can come to know about the Speed
of patient and Remedy along with the miasm
 Probable Diagnosis:-
H/O to rule out other disease

A/C:-

Past History:-Major illnesses which patient have suffered in the past.

In this try to elicit any major illness where in patient was not well after suffering from it.
 E.g.:- Never well since the last attack of typhoid.
 Any laser therapy done for calculi or as a corrective surgery for the eye,
Physical trauma.
 In children ask for the history of vaccination and how did child reacted to it?
(for e.g. did child developed any physical or mental complaints like for e.g. complaints
of Fever/ Rash/ Convulsions/ Giddiness/ Headache/ Mental restlessness/ Shrieking/
Dullness/ Drowsiness, etc. try to see which system got affected after the vaccination if
there was A/F vaccination C.N.S / R.S / G.I.T / SKIN / General)
Also try to see after which emotions does the patient have fallen ill most of the time.
Try to find the journey of disease in chronological order and the
Ascending nature of the disease layer wise.
Trace the Progression of Psora → Sycosis → Syphilis.
Family History :-Ask About hereditary illnesses in the family.

Gynaec/obs History :-
 Ask about the menses in details.
 Before, during, after menses any characteristic complaints.
 Ask about menarche was on normal age or it was early or delayed menarche.
 In menopausal woman ask the time of menopause normal--early--delayed.
 In obs H/o:-was there any habitual abortions or miscarriages.

Drug History:-
 In this ask to pt. is he taking any medications.
 Any allergy to a particular drugs or medicine
In this one should think about any chronic side effects of the medications if patient is taking for
long period as the presenting complaints or associated complaints.

Investigations:-Here note down all the significant findings which the Patient has got done already
[recently] regarding his general health or about his complaints.

GENERALS:-
 Appearance:- Built, Body structure, face, hairs, complexion, warts/moles/
frown on face, Discolouration or Pigmentation etc.
 Appetite:-How is your appetite. Non veg/Veg.
Can you tolerate your hunger or not.
What kind of food you prefer warm or cold or anything is ok with you.
Drinks:-what you like soft drinks or fruit juices and how often you ask for
Lemonades/juices, etc.
 Cravings & Aversion
 Food/drink-agg/amel.
 Thirst:-Ask how much water you drink in whole day; you feel thirsty i.e.
why you drink or as a habit you drink. or it is that you drink water during meals
only and you don't feel thirsty in between. Does your throat or mouth gets dry.
Prefer to drink cold/warm/room temperature water.
 Perspiration:-try to find any pqrs regarding perspiration of the pt.
 Stools
 Urine
 Thermals:-Ask pt. What can he tolerate more of heat or cold .
- Does he needs fan/A.C. all the time or he can be comfortable without it.
- Is he the first one to take sweaters or warm clothes or any covering in cold
atmosphere in the family.
 Sleep:-Sound /Alert, restless and continuous tossing on bed in sleep,
prefers which position to sleep. Salivation during sleep. Catnap sleep.
 Dreams:-good/bad, repeated dreams, related to family or his work.
Its affection in general
 Speed: How is your speed of doing your work, while walking, while talking, while eating.
 Side:- In this elicit side of the patient,Try to see which side of patient is predominantly
affected from S/S ,any Mole, injury marks ,scars, any pigmentation from birth.
 SENSITIVITY in general:-
To sun.
To noise [slightest /loud, etc].
To light [Bright /yellow’ etc].
To tight clothing's [around neck; around abdomen].
To touch.
To perfumes/strong odors.
To Atmospheric Conditions e.g. Rains, cloudy weather, Moon, Winds, etc.
If anything is there then how the patient is getting affected .
Ask for any allergic reactions to metals or any synthetic products.
 Senses:-Vision; Smell; Hearing; Taste; Extra Sensory Perceptions
 Habits:- Ask the patient does he have any habits like smoking, drinking or
tobacco chewing.

MIND & LIFE SITUATION:-Start the conversation with asking with whom they are staying
presently .Is that they stay in a joint Family or a nuclear Family.

 Ask about education qualification: - if not studied than ask why they didn’t study or they had
interest but couldn’t study because of some problems or they were interested in something else.

 Expressive or non expressive:-

i.e. Extrovert, Vivacious, loquacity, lamenting, Introvert, Reserved, Talk indisposed
to, quiet Disposition, Secretive.
- Expressive patients will start narrating their complaints as soon as they sit in front of you.
- Ask them that can they mix up easily in people around them.
- Do they love to talk and enjoy with people around them.
- Do they share their feelings with anyone?
Ask them what do they prefer to be in company or to be alone? & Why?

 ntellect & Morals:-

Intellect is Quality which tells about the Thinking Capacity i.e. reasoning and understanding; to
comprehend and react to a particular situation of an individual.
- Ask how they were in their studies – used to study of their own or Always someone had to be
there behind them for their studies.
- To a businessman or an employee ask how they handle their work (in this try to see whether the
patient is intellectually sharp, Comprehension easy, Reading desires, Sharpness of
Mind or Slow, Idiocy, Mistakes makes many, Childish behaviour, Ideas deficient of,
Concentration Difficult, etc.)
- Ask how good are they in making Decisions (can they take decisions themselves on spot or do
they think a lot and then decide or is it that they have to take someone’s advice for their decision
or till end they are in confused state being Indecisive.)
Morals is concerned with the good and bad aspects (traits) of human characters in acceptance
to rules and standards of human behavior. For e.g. Good Morals like Anxiety conscience of;
Obedience; Obsequious; Reverence. Etc and Bad Morals like Insolence; Gambling; perversions;
Morals want of cruelty, etc.
Also in this try to see whether the person sitting in front of you is Conscientious or
Non conscientious/ Diligent or Non diligent.
- Ask them whether they do their work/duty when they are not well? Why?
- In studies also were they very regular at school/college? Why?
- In Female’s ask they do their work inspite of their complaints? Why?

 Memory:-Ask the patient how good is their Memory power

- can they easily recollect things of past very well
- how good are they in remembering numbers & names
- try to find any characteristics regarding the memory of the individual
(Here the Physician should try to see any peculiar thing about the Memory like Memory active or
any Forgetfulness tendency/ Weakness of Memory.)

 Will:- [Faculty by which a person decides on and initiates action]

Will of a person can be elicited by asking the individuals what their reaction is in a crisis and also
trying to find out what measures do they take to avoid those crisis.
Ask them that can they handle any Responsibilities given to them alone any time.
- How confident are they in handling things alone.
- If something critical happens at home how do they deal with that situation
- Are they capable of handling situations Alone or their output is much secured
with some Support.(Support, want of)
- Ask them if any Injustice or something wrong is happening in front of them than what they do
or how do they react to it (Injustice cannot tolerate).
(Here try to see whether the person is Strong Willed, Confident, Courageous,
Self-dependent, Optimistic, Perseverance, Positivity or weak willed, Dependent,
Timid, Pessimist, Bashful, Embarrassment, cowardice, etc)

 Nature or Disposition: -
Angry/ Mild, Yielding/Weeping, Haughty/Timid/Sarcastic/Contemptuous,
Apprehensive/Fearful, Loquacious/Quiet, Contented or Discontented, Quarrelsome/
Fighter/ Revolter/Indifferent, etc.
- Ask them about their nature with people around them.
- Does he is more on angry side or towards calmer side.
- Whenever they get angry how they behave with those who are in front of them.
- Which is the thing or act which they can’t tolerate in their surroundings?
- Anger is Expressed or Suppressed
( If expressed then in which way verbally/ Physically, etc)
- Can they express their anger in front of everyone i.e even to their elders.
- Ask with whom so they got angry they will keep their relations with them.
- Do they keep thinking on the issue for which they got angry?
- Can they forgive those people who have hurt them or they will keep grudges for them.
- Will they take revenge when offended?
- Ask them how are they seen as a person in their society; Image amongst their friends;
- Image amongst the colleagues; Image amongst the relatives ?
 Sensitivity:- To Rudeness/Criticism/Relations/Social position/Money/Admonition/
Appreciation/Ego/Injustice, etc.
- Ask what is their reaction when someone talks / speaks to them Rudely or arrogantly
- Ask how do they React when someone points out or criticizes in their work.
(In this try to see the reaction of the individual like they get anger or feel hurt)
- Same way try to find out how do they get affected or are sensitive to Relations/
Social position/Money /Ego/admonition/Injustice, etc.

 Emotional:-
I.e. Sentimental, Grief, Sympathy, Affectionate, Rage, Jealousy, etc.
- Ask them their reaction whenever anything happens against their wish or will.
- Ask about their emotional sensitivity.
- Do they help person who come to them for help or they themselves go to the
needy person.
- Are they very much involved in charity work? Why?
- Do they get easily affected when they see someone in pain in front of them,
If Yes than what is their reaction?

 Anticipation /Apprehension i.e. Anxiety:-

- Here ask patient if any new work is said to them or something which is new for them asked to
be done how confident are they in accepting that work & what thoughts come to them.
- If you are supposed to reach at a place at a given time than do you reach on time or Get late or
reach before the time only.
- If you are told that some guests are coming at your place so how do you manage.
In anxiety try to see exactly for which thing the patient is more worried of eg.
Anxiety health
Anxiety children
Anxiety family
Anxiety for others
Anxiety of future
Anxiety trifles about
Anxiety anticipating engagement
Anxiety salvation
Anxiety conscience –it is a feeling of Guilt conscience or feeling where one blames themselves
for some Sin or bad thing happened (or can happen in future) to others because of them.
 Attachment:-
- Ask whom are they most attached to.
- Ask them which is the most important thing for them in their life e.g. Career, Family,
Friends, Business, Name & Fame, Money, etc
- Ask them whenever they are ill or not feeling well and people around them like family member’s
or relative’s & Friends ask about their Health then what do they feel?
(Consolation, Sympathy Desires or aggravates).
- If any family member for e.g. anyone of the parents or siblings or children gets unwell then how
do they react? Do they show concern and worry or it doesn’t affects much (Ask this question to
the accompanying person with the Patient) Try to see how much he/she is affectionate/
caring/ concern/Indifference to their loved one’s.
 Fears:-Ask about the fears.
 Childhood History: - Here one should ask about the whole childhood nature and Experiences or
interests, etc. in detail. For e.g.:
- Esp. nature as a child from 0-6 years of age?
- What kind of child you were accounted as for e.g. Mild, silent, fearful, timid, weeping, reserved,
introvert, extrovert, cranky, angry, obstinate, mischievous, destructive, obedient, studious,
yielding, etc.( ask for incidences to deduce such traits)
- Which qualities of your childhood days are remembered by your parents and relatives?
- When he/she went to school first time how was the reaction?
- When guests would come to home how would be his/her reaction?
- Reaction with other children in surrounding?
- Which qualities of childhood are still remembered by you?
- Image in school amongst teachers?
- Reaction before exams.
- Was he daring in acts and sports activities?
[Please ask for life incidences to get one’s disposition and original traits.]

Try to elicit how the patient is mentally Sensitive to:

 Behaviour of others: Rudeness, Criticism, Reproach, Contradiction.
 Surroundings: Music, Nature, Cleanliness, Religion, Animals.
 Self: Health, Money, Ego, Honor, Work, Discipline, Position, Success, Failures.
 Relationships: Attachments with Family, Friends, Bonds.

But the most important thing which a physician can never forget in whole case is the Cause of the
Disease i.e. A/F which should be elicited by skillful conversation with the patient.
To take A/F as the prescriptive or the entry point in the case one should see to it that Cause
should be Recent and Related.

So one should keep in mind that for a psoric disease the cause has to be a psoric e.g.
Psoric causes:
Irritability, anger, hurt, mild, grief
Anxiety, worry, anticipation
Angry when obliged to answer
Sensitivity (Rudeness, criticism, neglect external impression, disharmony & Quarrels, joy, light,
noise, music, odour, touch, pain).

For a Sycotic illness in a patient the cause has to be Sycotic e.g.

Sycotic causes:
Sensitive to slow and stressful, prolonged stress
Prolonged grief, vexation, stress
Brooding disappointment in love
Anger suppressed, mortification, after long domination
Nursing the sick
Grief from loss of money / position, loved ones
Business cares / house cares

And similarly if the patient is in Syphilitic Disease the cause has to be Syphilitic e.g.
Syphilitic causes:
Violent, strong and destructive sudden
Shock, insult, humiliation, abuse
Honour wounded
Sudden anger, rage
Fright, panic
Strong anger suppressed
Sudden loss of loved ones
Sudden joy
Sudden loss in business, money, prestige
Drugs and suppressions in general
Physical trauma

But one should keep in mind that if patient gives you any h/o of any cause for his ill health in past
so one should correlate it with the disease miasmatically.
If miasm has bloomed then the cause is not important.(footnote 120).

After Listening or taking the whole case don’t rely completely on patient.
Carefully Observe your Patient for
- How was he talking to you?
- How was he answering your questions?
- What was the quality of speech?
- How were the expressions of the patient about their sufferings during whole conversations?

Never totally belief the patient blindly try to see whether the person sitting opposite to you is a
Honest/Liar/Boaster/Manipulative while taking the case, cross examine your Patient.

There are many certain things which one cannot forget to make their note of while taking the case
themselves about the patient by the physician e.g.
- Jesting.
- Affectation.(Artificial behaviour)
- Bashful.
- Naiveness.
- Cautious.
- Coquettish/Flirting.
- Buoyancy
- Censorious/Critical
- Sarcastic.
- Restlessness/Hyperactivity/Hurried Nature.
- Effeminate/Mannish behavior.
- Graceful.
- Obsequious.
- Gestures.
- Lamenting.
- Begging.
- Clinging.
- Frivolous.
- Inciting.
- Crank.
- Shameless.
- Foppish.
- Vanity.
- Loquacity.
- Talking speed
- Attention Seeking or Playing Antic’s.
- Self-esteem or Ego.
- The way patient laughs or talks.
- The way Patient Sits in front of you.

Some Emotional Causes And Life Events Affecting Different Age Group:
In Age Group From Infants To Toddlers:
- Fear or Fright out of a sudden fall or scolded by someone; toddler getting afraid of new people or
suddenly someone shouting at them; Child was exposed to something new for the first time esp.
some religious Rituals or any procession where lot of people and noise scared him.
- Child is frequently exposed to Parent’s Quarrels or Discords.
- Mother of the child being subjected to harassments from In laws in front of the child.
[Child seeing mother weeping very often may develop feeling of insecurity and Grief]
- Discords among other Family members happening at home in front of the child.
- Witnessing domestic violence is terrifying to children and emotionally abusive. Even if the mother
does her best to protect her children and keeps them from being physically abused, the situation
is still extremely damaging mentally for the children.
- Mother is a working female so resumes for her job: Mother who was looking after her Child for 1 st
few months after the birth of the baby resumes her Job.
- Child is kept away from mother because mother having some chronic infectious disease
recurrently falling ill or mother has some mental illness where she is unable to take care of
the child.
- In between parents went for 1 or 2 days leaving the child with the Grandparents or with the
Relatives.
- Childs Basic demands being neglected by the parents or by the caretaker of the child
(demands may be for adequate food, attention, clothing, to play, to go out, hygiene, etc.)
- Child got frightened by seeing or coming in contact with any pet animals like dog, cat, etc.
- Sibling jealousy: New born sibling in the family.

Amongst School Going Children:

- Sibling jealousy
- Punishment in school
- Child Loosing rank in class.
- Being neglected amongst friends.
- Being compared with the siblings or other children by parent’s or other family members.
- Humiliation in class from the teacher.
- Domination from the parents or any other family member.
- Parent’s Quarrels or Discords, missing working parents.
- Failing in studies.
- Failure in any extracurricular activity- for e.g. not being selected in team or for any other group
activity, disappointment in cultural activity.
- Feeling Discriminated in the class by some teachers
- Child living with an alcoholic or addict Father is very difficult and can easily lead to abuse and
neglect of the child.
There are other certain small things which happen very often with most of the school going children
but how does the child react to such events are not noticed by many of us which is very important
for us to ask in Childhood history for e.g.
- Constant belittling, shaming, and humiliating a child.
- Calling names and making negative comparisons to others.
- Telling a child he or she is ―no good," "worthless," "bad," or "a mistake."
- Frequent yelling, threatening, or bullying.
- Ignoring or rejecting a child as punishment, giving him or her the silent treatment.
- Limited physical contact with the child—no hugs, kisses, or other signs of affection.
- Exposing the child to violence or the abuse of others, whether it be the abuse of a parent,
a sibling, or even a pet.

Amongst College Students:

- Failure in getting to the desired career.
- Problems with friends.
- Disappointment in love.
- Failure in studies.
- Inferiority complex about money, status, looks, clothes, etc.
- Sexual abuse.

Amongst Middle Age:

- Financial loss; Financial stress.
- Problems at the working place - Falling short of capabilities as compared to other colleagues,
injustice or certain discrimination by the superiors or the colleagues, working against the will,
Physical or sexual abuse [esp. for working females].
- Marital relationship [extra marital affairs]
- Couple not conceiving.
- Social embarrassment for [e.g. someone did wrong in family for which the Police came
to the house for the first time so the person felt it was better if he would not have
been alive to see such incidence; Son or Daughter marrying to intercaste spouse]
- In joint family again feeling of Discrimination by the superior of the family in
comparison to other members.

Note: Proforma for case taking is not a hard and fast rule to take a case in this pattern
only.
 GENERAL PHYSICAL EXAMINATION
The general physical examination is done following the history taking. It provides
adequate clue to the diagnosis. The general physical examination begins as the patient
enters the consultation room and continues during the entire history taking and during
the examination of the subject.

Pr-requisites:

 The examination should be carried out in good day light.

 The examiner must stand on the right side of the subject.
 The comfort of the subject should be given priority while selecting the position.
 The examination should be carried out in the presence of a bystander.
 The subject should be made comfortable for an effective examination.

The general physical examination should be carried out under the following headings:

1. General appearance

The subject looks healthy, unwell or ill and its severity is to be assessed.

2. Mental state and intelligence

a. Assess the mood and emotional state of the subject.

b. Assessment of intelligence is done from occupational, educational background and
the general knowledge of the subject.

3. Consciousness and cooperation:

Ascertain the level of consciousness i.e. clear sensorium, drowsiness, stupor, coma etc.
In fully conscious subject assess whether the subject is cooperative to give necessary
information.

4. Posture

It is the position adapted by the subject.

The position adapted while lying down in the bed is called decubitus. Normal decubitus
is where the subject lies comfortably with free movements of the limbs.
The position adapted when standing is called attitude. The normal attitude is where the
person stands erect. Slight bending is common.
The position adapted while walking is called gait.

5. Facies

The expression on the face should be assessed.

6. Build and Nutrition

Build is the skeletal structure of a person. It is assessed in relation to the age and sex
of the person. It should be observed whether the person is lean or fat, tall or short,
muscular or asthenic.
Measure the bulk of the muscle. (average in males- 25.5 cm and females 23 cm)

7. Height

The height of the subject is measured.

If the person is too tall or too short, measure the span i.e. measurement from the tip
of the middle finger of one hand to the middle finger of the other hand in outstretched
upper limbs or measure the upper segment (i.e. from crown to pubic symphysis) and the
lower segment (pubic symphysis to foot). Normally in adult the arm span is equal to the
height and upper segment is equal to the lower segment.

8. Weight and Body mass index

The weight should be recorded with minimal clothing and barefoot

Body mass index is measured by weight in Kg divided by body height in metre square.

BMI = Wt in Kg/ Ht in m²

Normal BMI is 18-25

Under weight --BMI is less than 18.
Over weight = BMI 25 to 30
Obesity BMI 30 and above

9. Skin and Mucous membrane

A) Pallor

It is the paleness of the skin and the mucous membrane. It depends on the thickness
and quality of the skin.
It is detected by examining the lower palpebral conjunctiva, tip and dorsum of the
tongue, soft palate, mucous membrane of the cheeks, nail beds and palmar creases.
Pallor is seen in person with thick skin, hemorrhage, syncope and severe anemia.

Pallor is graded as

P0 no anemia
P+ mild anemia
P ++ moderate anemia
P +++ severe anemia
B) Jaundice

Yellow discoloration of the skin and the mucous membrane.

It occurs due to the presence of excess bilirubin in the blood. Normal serum bilirubin
concentration is 0.2 to 1 mg / dl of blood. When bilirubin level exceeds 2mg %.
jaundice appear clinically. It is detected by examining the sclera, nail bed, soft palate
and under-surface of the tongue.
It is caused due to the destruction of the RBCs, hepatitis, damage to the liver cells and
obstruction to the biliary tract.

C) Cyanosis

Bluish discoloration of the skin and the mucous membrane.

It occurs due to the presence of reduced Hb more than 5 gm% in the blood.
Classified as central, peripheral and mixed
Sites to be looked for cyanosis are tip of the nose, car lobules, lips, tip of the fingers
and toes, nail bed, palms and soles, tip and undersurface of tongue etc
Occurs due to exposure to cold, venous obstruction, decreased cardiac output, mitral
stenosis, CCF, cor pulmonale etc

D) Clubbing

Obliteration of the angle between the nail base and the adjacent skin of the finger.
Occurs due to the thickening of the tissues at the nail base.
Examined by placing the nails of the 2 fingers facing each other. Normally a space is
seen; if lost called schamroth's sign.

Causes-congenital heart diseases, bronchiectasis, long standing tuberculosis, lung

abscess, mal-absorption syndrome etc

Graded as

i. Ist degree increased fluctuation of the nail bed.

ii. 2nd degree - 1° + curving of the nail
iii. 3rd degree angle at the base obliterated parrot beak appearance.
iv. 4th degree swelling of the finger associated with subperiosteal thickening of the wrist
bone.

E) Edema

It is the swelling of the skin and the subcutaneous tissues due to the accumulation of
the free fluids in excess in the interstitial tissue space.
It is classified as pitting or non pitting and generalized or localized.
Assessed by pressing against the bone in the dependent parts
Occurs in cases of local inflammation, filariasis, anemia, hypoproteinemia, cardiac
diseases,hepatic disorders, renal diseases etc.
F) The skin is also examined for any pigmentation, eruptions, scars and secondary
lesions. The skeletal deformities if any should be noted. Hands should be examined for
any nodules, deformities, tremors etc. The nails should be examined for any
discoloration, depressions, deformities etc.

10. Lymph node examination

Enlargement of the lymph nodes to be looked for

In case of enlargement - check for its site, size, number, consistency, mobility,
tenderness.etc

11. Oral hygiene

Oral cavity i.e. the health of the gums, teeth and cheeks should be examined as it gives
certain clues towards the nutritional deficiencies.

12. Vital signs

The general physical examination is concluded by assessing the vital signs such as
temperature, pulse, respiratory rate and blood pressure.
 2. MEDICAL THERMOMETRY
The art of taking and recording the body temperature is called the medical
thermometry.

Apparatus used:

Clinical thermometer, cotton, antiseptic solution, water and watch

Clinical thermometer:

Clinical thermometer is a self registering glass apparatus. The graduations are marked
from 95° to 110° in Fahrenheit scale and 35° to 42° in centigrade scale. In its
construction, a constricted twist forms the junction of the main bulb with the capillary
limb. It prevents the contraction of the mercury back to the bulb when the temp falls.

The thermometer has a curved surface which acts as a lens and magnifies the width of
the mercury and a flattened surface that lessens the danger of breakage from rolling.

The flat back is painted white against which the temp can be read with ease.
To convert the Fahrenheit reading to centigrade, formula used is C =(F-32) x 5 / 9
To convert the centigrade reading to Fahrenheit, formula used is F = (C x 9)/5 + 32

Procedure:

The clinical thermometer is sterilized thoroughly with nonpoisonous antiseptic solution

such as 5% dettol or rectified spirit.
It should be cleaned with clean cool water and wiped in the presence of the subject
before use.

The mercury level should be shaken down before use below 95° F by quick wrist
movements holding the thermometer at its upper end.

The sites used to place the thermometer are mouth, axilla, rectum and vagina (in case of
infants and a comatose subject), groin with flexed thigh over the abdomen (in case of
infants).

The thermometer should be placed in such a way that its bulb is completely covered by
the tissues from all sides. Skin should be dry, clean and unexposed to the surroundings.
No fold of clothing interfere the contact of the instrument with the skin. Hot or cold
drinks taken prior to the recording can alter the temperature recorded orally.

In the axilla, the bulb should be placed in the hollow and arm is flexed across the chest
so that no air is trapped in the axilla.
In the mouth, the bulb is placed under the tongue and the lips are firmly closed around
the stem and the subject is asked to breathe through nose. Recording oral temp is not
safe in young children, mentally retarded or convulsive state or person with delirium.

Place the thermometer in position. Read and record the temperature after one minute.
Bring down the mercury level and again repeat the recording each time increasing the
duration by half a minute. The recording of the temperature continues till the three
consecutive readings do not show any alteration.

Wash the thermometer after use and place it in a container having a cotton wool pad
placed at the base and filled with antiseptic solution.

Discussion:

The normal body temperature ranges from 36.6 to 37.2°C or 98° to 99°F (Average is
37°C or 98.6°F). The oral temperature is 0.5 to 1°C higher than the axillary temperature.

“Core temperature” is an accurate index of the teraperature of the blood to which the
hypothalamic thermoregulatory receptors are exposed and it is maintained at a
constant level. It is recorded in the tympanic membrane, rectum, vagina and esophagus.
It is 0.5 to 1º C more than the oral temperature.

The hypothalamus regulates the body temperatur it has 2 centers - 'heat gain center' in
the posterior hypothalamus and heat loss center in the anterior hypothalamus.

The mechanisms activated by exposure to cold are:

A. The responses which increases the heat production - shivering, hunger, increase
voluntary activity, increase secretion of TSH and catecholamine.
B. The responses which decrease the heat loss - cutaneous vasoconstriction, curling
up,erection of hair and behavioral changes.

The mechanisms activated by exposure to heat are

A. The responses that increase the heat loss cutaneous vasodilatation, sweating and
increase respiration
B. The responses that decrease the heat production - decrease BMR, decrease body
activity, decrease TSH secretion and behavioral changes.

Fever or pyrexia refers to an elevated body temperature above 37° C or 99°F.

It is of 3 types - continued, intermittent and remittent

Continued fever - does not fluctuate more than 1° C during 24 hours period and at no
time touches the normal
Remittent fever show fluctuation more than 2° daily and never touches, the baseline
Intermittent fever -fever present only for several hours and always touch the baseline
sometime during the day and the paroxysms are quotidian, tertian or quartan.

Hyperpyrexia is the temperature above 41.6°C or 106°F

Hypothermia abnormally low temp of below 35° or 95° F temperature below 36.6°C or
98° F
Subnormal temperature - temperature below 36°C or 98° F
 3. EXAMINATION OF PULSE
Aim:

To examine the arterial pulse.

Requirements:

Wrist watch with second hand

Procedure:

The arterial pulse is detected by gently compressing the vessel against some firm
underlying structure, usually a bone.
The radial pulse on either side is examined first as this pulse is commonly used to asses
the heart rate.
The right forearm of the subject is held in the semi-prone position with slightly flexed
wrist and the radial pulse is felt with the tips of examiner's three middle fingers. The
proximal finger varies the pressure on the artery, middle finger feels the pulsation and
the distal finger prevents reflection of the pulsations from the palmar arch of the
arteries.

The information collected on the following points -

Rate - the rate of the pulse noted as beats per minute. The subject is made to relax for
few minutes before the examination. The pulse is counter for complete one minute. The
pulse should not be counted as soon as the fingers are placed on the wrist, instead wait
till the nervousness of the subject subsides. Consecutive 3 readings are taken. In healthy
person who is at complete mental and physical rest, the consecutive rates do not differ.
The readings may show changes when the person is not at rest.

Rhythm The normal pulse waves appear at regular interval. The rate and rhythm
should be compared with the cardiac impulses.

Volume -The volume refers to the amplitude of the movement or expansion of the
artery during the passage of the pulse wave. The pulse may have large, moderate and
small volume. It is constant from beat to beat.

Character of the pulse -It describes the impression of the pulse waveform gained by the
palpation. The pulse wave has an upstroke and a down stroke. It shows a tidal or
percussion (p) wave, which occurs due to the ejection of blood from the ventricle during
systole. The dicrotic (d) wave occurs. due to the rebounding of blood against the closed
aortic valve during diastole. The dicrotic (n) notch represents the closure of the aortic
valve. The character is usually described as normal.
Condition of the vessel wall After emptying the radial artery, the proximal and the
distal fingers are pressed to cause a complete obliteration of the pulse over a segment
of the artery. Then the middle finger is pressed sufficiently hard and the artery is rolled
laterally over the bone beneath to feel the texture of the artery.

It is palpable in case of atherosclerosis and calcification.

Equality on the two sides -The pulse of the other arm is examined in regard to the
above mentioned points and comparison is made between the two

Peripheral pulses

The main peripheral pulses involved in the examination are

Radial artery - the radial artery is compressed against the lower end of the radius, on
the flexor surface of the wrist.
Brachial artery - is compressed against the humerus just above the anticubital fossa
medial to the biceps tendon

Carotid artery - Inspect the neck for pulsations. The carotid pulsation may be visible
medial to the sternocleidomastoid muscle. Press inside the medial border of the well
relaxed sternocleidomastoid muscle at the level of the thyroid cartilage.
The right carotid is examined with the left thumb and the left with the right thumb.
Precaution is to be taken not to press both the carotid simultaneously, which may
decrease the blood supply to the brain and cause syncope.

Femoral artery - lies midway between the iliac crest and pubic ramus, below the
inguinal ligament In obese person both the hands placed one above other are used to
feel for the pulse.

Popliteal artery The fingertips of both the hands are placed in the popliteal fossae
with the thumbs resting on the subject's patellae during the flexion of the knee.

Posterior tibial artery - is found one cm behind the medial malleolus of the tibia,
midway between the tendoachillis and medial malleolus.

Dorsalis pedis artery - is felt by compressing the artery against the tarsal bones on the
dorsum of the foot, just lateral to the extensor tenon of the great toe.
Discussion

Pulse is the expansion and the elongation the pressure changes during systole and
diastole of the ventricle. walls passively produced by the pressure changes during
systole and diastole of the ventricle.

The normal pulse rate ranges from 60 to 100 beats per minute and averages about 72/
minute. It varies with the age. In the fetus it is about 140/min, new born 130/min, at the
age of 10 years it reduces to 80/ min and at the age of 20 it becomes 70/min.

The pulse rate increases during inspiration and decreases during expiration. When it
occurs during quiet breathing it is called Sinus arrythmia. It occurs due to the irradiation
of impulses from the inspiratory center to the cardiac center.

An increase in pulse rate above 100 per minute is called as Tachycardia.

Physiological causes -

Emotional excitement, nervousness, muscular exercise, in newborn, during pregnancy,

diurnal variation i.e increases towards evening etc

Pathological causes -

Fever (i.e. for every 1°C rise in temperature, the pulse rate increases by 10 to 14 beats).
thyrotoxicosis, atrial flutter, atrial fibrillation, circulatory shock, paroxysmal atrial
tachycardia etc

Decrease in the pulse rate below 60 per minute is called as Bradycardia.

Physiological causes -

Athletes (pulse rate is 50 to 55 /min during rest in athletes due to increase vagal tone),
sleep, meditation, basal condition (i.e. before the person gets out of bed after a good
sleep)

Pathological causes -

Myxedema, heart block, general weakness and debility, drugs etc.

The rhythm can show two types of irregularities

Regularly irregular - seen in extra systole

Irregularly irregular - seen in atrial fibrillation
The volume decreases with rapid rate and weak small wave called thready pulse seen in
cardiovascular shock, severe dehydration etc and increase called bounding pulse- seen
in fever, pregnancy, thyrotoxicosis etc

The abnormal characters of the pulse are

Slow rising pulse or Anacrotic pulse

It is seen in aortic stenosis. The pulse rises slowly with large systolic peak.

Collapsing or water hammer pulse - It is seen in aortic regurgitation, patent ductus

arteriosus, arterio-venous pulse shows a rapid upstroke and down stroke.

Bisferiens pulse
It is a combination of slow rising and collapsing pulse seen in mild aortic stenosis and
severe incompetence.

Pulsus paradoxus - It is seen in large pericardial effusion or severe asthma. Here the
arterial pressure falls during inspiration. The paradox is that the heart sound may still be
heard over the precordium when no radial pulse is palpable.

Pulsus alternans - When the left ventricle is severely diseased it may develop alternate
strong and weak beat.

Pulse delay -
When the left femoral and right radial artery is palpated simultaneously, they normally
beat together. A delay is seen in femoral artery in case of coarctation of the aorta.

Pulse deficit -
Normally the pulse rate and the heart rate are identical. But in case of extra systole and
atrial fibrillation the ventricular beats are too weak to be felt at the radial artery, so that
the heart rate remains higher than the radial artery.
 4. DETERMINATION OF BLOOD PRESSURE

Aim:

To determine the blood pressure of the subject.

Requirements:

Mercurial sphygmomanometer, bed, stool and stethoscope

Mercurial sphygmomanometer:

It consists of three parts

Mercurial Manometer
A rubber bag with linen cuff
Air pump or rubber pump

Mercurial manometer - Has two limbs. One is long narrow and graduated from 0 at
the base to 300 at the top and each division represents approximately 2mm. It is open
at the upper end and fitted with the valve that prevents the spilling of the mercury. The
other limb is short and broad, which acts as a reservoir of mercury. It is an airtight limb
where the upper end is fitted with the metallic adaptor and the lower end to the rubber
A locking lever disconnects the reservoir from the tube.

Rubber bag with linen cuff- also called Riva Rocci cuff. It consists of inflatable rubber
bag covered with non distensible cloth. The rubbehag in adult measures about 12cm
(width) x 24cm (length). This width helps to cover the maximum segment of artery as
the pressure exerted is in the form of a cone. It varies in different age group and with
body built i.e. smaller for children and larger for obese people. The bag is fitted with two
rubber tubes- one connects it to the mercurial manometer and other to the rubber
pump.

Rubber pump - oval shaped simple rubber balloon. It is used to inflate and deflate the
rubber bag.

Stethoscope:

It has 2 ear knobs, which are joined via metallic tube to the Y shaped rubber tube. The
conducting tube in turn connected to the chest piece.
The chest piece has 2 parts - Bell and Diaphragm. Bell is used to auscultate the low pitch
sounds while the diaphragm is used for the auscultation of the high pitch sounds.

Principle:
When the cuff is wrapped around the arm and the air pressure is raised above the
arterial pressure, the blood flow is obstructed. On releasing the pressure, the blood
starts flowing through a narrow passage is studied by feeling the pulse - palpatory
method or by hearing the sounds with the stethoscope - auscultatory method.

Procedure:

The examiner is standing on the right hand side of the subject.

Deflate the rubber bag completely by squeezing the cuff.
Place the bag on the bare arm in such a way that it covers half the girth of the arm. Tie
the cuff 2-3 cm above the cubital fossa. Tying should not be too tight or too loose and
the rubber tubing should be on the sides of the arm.

The rubber pump is held in the left hand with the thumb and the index fingers are on
the screw for adjustment.
Make sure that the lever lock at the mercury manometer is opened before inflating the
cuff.
The manometer should be at the level of the heart to avoid gravity effect and the
graduations are seen clearly by the examiner.
Ask the subject remain relaxed and then inflate the bag by compressing the rubber
pump repeatedly to assess the blood pressure.

The blood pressure can be recorded by three methods -

a) Palpatory method
b) Oscillatory method
c) Auscultatory method

Palpatory method
After the completion of the preliminary adjustment, feel for the radial pulse with the
right hand.
Then inflate the rubber bag till the radial pulse disappears.
Note the reading from the manometer. This is recorded as the systolic pressure.

The disappearance of the pulse can be confirmed by raising the pressure 10mmHg
above the recorded reading and then slowly bringing down the mercury level. The pulse
reappears exactly at the same level at which it has disappeared

Significance - it gives a rough idea about the systolic pressure before recording the
blood pressure by other 2 methods i.e. it gives an idea about how much the pressure
should be raised for the other methods which is 30mmHg above the systolic pressure. It
also helps in avoiding the missing of the auscultatory gap if present. By this method,
diastolic pressure can not be determined..

Oscillatory method -

After recording the blood pressure by the palpatory method, raise the mercury level 30
mmHg above the recorded systolic pressure and then slowly release the pressure. The
mercury in the manometer shows oscillation as the pressure becomes equal to that of
 the systolic pressure. The level at which the first oscillation seen is the systolic pressure.
As the pressure is reduced further the oscillations increase in amplitude. The level at
which the maximum oscillations seen is considered as the diastolic pressure.

By this method the accurate blood pressure cannot be assessed.

Auscultatory method -

Raise the pressure 30mmHg above the recorded systolic blood pressure by the
palpatory method. Place the stethoscope over the brachial artery (medial to the biceps
tendon just above the cubital fossa). Then reduce the pressure slowly and as the
pressure decreases the sounds are heard. The level at which the sound heard for the
first time is the systolic pressure and when the sound disappear is the diastolic pressure.

Observation:

Name of the Posture Palpatory Auscultatory Pulsepressure Mean arterial

subject method method pressure

Supine
Sitting
Standing

Discussion:

Blood pressure is defined as the lateral pressure exerted by a column of blood on the
vessel wall while flowing through it.

The average blood pressure is 120/80 mmHg.

Systolic blood pressure

It is the maximum pressure produced during the systole of cardiac cycle. It ranges from
100 to 140 mmHg.

Diastolic blood pressure -

It is the minimum pressure recorded during the diastolic phase of the cardiac cycle. As
the diastolic pressure duration is longer it can cause more damage to the blood vessel
so this is more dangerous than systolic pressure. Diastolic pressure ranges 60 to 90
mmHg.
Pulse pressure - It is the difference between the systolic and diastolic pressure. This
pressure maintains the normal pulsatile nature of the blood flow in the vascular
compartments. It ranges from 20 to 50 mmHg (average 40mmHg)

Mean arterial pressure -

It is the average of all the pressure recorded during the cardiac cycle. Since the duration
of the systolic pressure is shorter than the diastolic pressure, it is slightly less than the
average of both the pressures. Hence it is calculated by adding 1/3rd the pulse pressure
to the diastolic pressure. Mean arterial pressure ranges from 75 to 105 mmHg

Korotkoff sound - The korotkoff sounds are those sounds heard with the stethoscope at
the brachial artery while the pressure is recorded.

Normally the blood flow through the artery is streamline and no sounds heard with the
stethoscope. When the cuff pressure is raised above the systolic pressure it obliterates
the artery. On reducing the pressure, blood starts jetting through narrow vessel at the
high velocity producing turbulent blood flow. Also the blood column in the distal part of
the artery set into vibration. Both the effects results in the production of the sound.

The sounds are heard in different phases

Phase I sudden appearance of faint tapping sound
Phase II- the sound becomes mumurish
Phase III sound is clear and loud called gong sound
Phase IV sound is muffled in character
Phase V sound disappears

Auscultatory gap -

In some hypertensive patient, a gap in the korotkoff sound is found i.e. as the mercury is
lowered a faint tap is heard which soon disappear and then again reappear at the lower
level. This gap is called auscultatory or silent gap.

Hypertension -
It is the chronic elevation of the blood pressure above 150/90 mmHg.
Classified into 2 types
Essential or primary hypertension
Secondary hypertension

Hypo-tension -
It is a condition where the pressure is below 90/50 mmHg
Classified into
Chronic hypotension
Acute hypotension
Postural hypotension