HOW TO EXAMINE A PATIENT?

1. Take the History of his present complaints —how and when it commenced; what aggravates it and what relieves it. For example, the illness might have followed an exposure or a heavy meal or a very superhuman muscular strain. The symptoms may be worse at night, aggravations may occur at 11 A.M. daily; massage may bring relief; movements may increase pain; at left decubitus may be comfortable; and so on.
2. Ask for the family history—if anyone in his family (on either parent’s side) had the disease.
3. Enquire to the patient’s occupations and
4. Enquire what his subjective symptoms are —g., a feeling of chill, headache, dizziness, aches and pains, bitter sensation of mouth, heart-burn, a sense of impending calamity, etc.
5. Take his Temperature by means of a good clinical thermometer. This is a small glass instrument on which occur sixteen equal marks ranging between 95° Fahrenheit and 110°F. The temperature below 98.4°F. by mouth (indicated by the arrow-mark) are called sub-normal and they indicate depression; the lower the temperature (a temperature near 95°F), the greater is the danger. The temperature 98.4° is said to be the normal temperature in health. The temperature can be taken by inserting the narrow end of the thermometer (the bulb), containing mercury either inside our mouth under the tongue, in the arm-pit or into anus. In this country, the arm-pit is usually chosen and the difference of temperatures between oral and auxiliary (or arm- pit) is one-degree Fahrenheit F in favor of the auxiliary temperature. To take the temperature, wipe out the arm pit or auxiliary and place the bulb at its middle and press the arm well against the side of the chest, so that, the bulb may be in firm good contact with the body, no air passing over it. It is customary to keep thermometer in this state for at least five minutes if not longer. It is wrong to believe that the temperature will be indicated higher, if the thermometer is kept longer. A very high temperature in itself is killing, if it is somewhere near, 107° F or so. A temperature of 105° F or os, if long persistent, is almost sure to induce congestion of such important organs as brain, liver, lungs etc. In old men, a temperature of over 101°F often induces delirium. In adults this is hardly the case. Remember that Fever is not a disease—fever is but a symptom or outward indication of some position circulating in the blood or of some disturbance of the nervous mechanism of the body.

It is idle, therefore, to think of getting down the temperature without, at the same time, trying to cure the causative mischief. In malaria, rheumatic fever, blood- poisoning and plague—the temperature suddenly rises to over 105°; this is called hyperpyrexia. A sudden fall of temperature to sub-normal in a case of typhoid fever or any acute disease is often a grave omen. In cases of pneumonia, such sudden falls are common and often usher convalescence. An evening rise of temperature with a flushed face and in morning normal temperature is called a hectic or wasting type of fever. A fever in which temperature daily comes down to normal or sub-normal is called intermittent fever; one in which the temperature merely comes down, but not to the normal level is called remittent fever. The fall of temperature to sub-normal level is not, in itself, alarming. When along with a sub-normal temperature, there are copious sweating, restlessness and panting for air, with cold and bluish extremities, the patient is then said to be in a state of collapse.

6. Pulse: We repeat, lightly feel it and not tightly compress it. The pulse gives us an idea of the condition of the body’s most important organ—the heart. So long as the heart is all right, we have hopes of holding out. But the heart is not only working day and night, it receives the first and the biggest dose of any poison, that may be circulating in the blood. Hence, in all diseases, the pulse affords us the best guide to the condition of heart and enables us to take steps betimes. We shall speak of the pulse in detail when describing “Diseases of the circulatory System” It is important here to note the number of beats that are normal to certain ages

The beats are about ten more in females, age for age, and in both sexes, they increase after meals and exertions and decrease during sleep. An intermittent pulse, a decrease of 20 beats per minute, and a full bounding pulse in an exhausted condition of health are signs of grave consequence.

7. Breathing: Normally, a child of one year, breathes 35 times a minute; of two years, 25 times; a man aged between 15 and over, breathes 18 to 20 times a minute. The normal breathing is a quite an easy one and it feels warm to the touch. The quicker and cooler the breathing is, the greater is the danger to life. In some cases the difficulty in breathing is so greater that patient has to sit up in order to be able to breathe freely and comfortably—it is called When in consequence of difficulty of breathing, the face, tips of fingers and toes, the ears, tips of nose, etc. look bluish, the condition is called cyanosis. In some conditions, however, much the room is open and airy, the more the patient wants air and tosses about in bed, throw about his limbs, breathes quickly— because air does not enter his lungs sufficiently; this condition is one of air-hunger and it is a very alarming one.
8. Note the relationship between pulse, respiration and temperature. Normally, for every degree of temperature above the normal, there occur ten extra beats of the pulse and two extra respirations. Thus, for-

9. Tongue It is not only a mirror to the condition of the alimentary passage, but is a good guide to the condition of the nervous system as well. We tabulate below the conditions of the tongue usually met with.
   1. It may be coated or furred-Furring may be due to general causes like fever or faulty stomach, intestines or liver; to local causes, like enlarged tonsils, in which case the back of the tongue is furred; to decayed tooth or to neuralgic pains. If due to general causes, the furring cleans up during convalescence. In tardy convalescence the cleaning up is in flakes. A milk diet also gives a white- fur.
   2. It may be dry—A dry tongue means wakefulness during night, or nervous prostration, or excessive loss of fluid from body and it calls for prompt attention. A dry tongue, if coated brown, indicates profound prostration and an intense amount of poisioning of the system. In such cases, the lips and teeth are covered with sordes. The tongue of nervous people is pale, dry, covered with a thin froth. Mouth-breathers too have dry and furred tongue.
   3. It may be flabby—e., it appears to be pale, flat and too big for the mouth, hence, its sides are indented with teeth marks. Such a tongue is seen in anaemia, wasting diseases, Bright’s disease and dyspepsia.
   4. It may look like raw beef—deep red, glazed smooth, clean and shiny. This is seen in diabetes.
   5. It may look red with prominent papilloe—most marked at the tip. It is seen in dyspeptics and drunkards.
   6. It may be strawberry like—red papillae showing through a white coated tongue. This is seen in scarlatina.
   7. It is blue or even blackish—in condition of embarrassed circulation (as in heart disease, emphysema, etc.).
   8. It is paralyzed—being either immobile or put out on only one side; this indicates paralysis.
   9. It may show ulceration—These are due to decayed teeth (in which case, the ulcer will be found opposite the faulty teeth); to dyspepsia-when the ulcer occurs chiefly on the under-surface of the tongue; to syphilis—occurring at the sides and tip, irregular in outline, breaking down at one spot and cicatrizing at another.
   10. It is tremulous and foul—in alcoholics.
   11. It shows signs of having been bitten—It indicates that the patient is probably epileptic.
   12. It is swollen with white fur—It indicates that the patient suffers from nervous derangements of the digestive organs, reacting upon the brain and producing congestion.
   13. It is cracked, furred, fissured, swollen—It represents the severe derangements of the stomach.
   14. It is thickly, furred, dirty, white or brownish without dryness, enlargement or redness—It suggests that the lining membrane, rather than the nerve of the stomach—is deranged.
   15. It is blackish, dry, furred and tremulous—it is indicative of a severe condition in abdomen.
   16. It is swollen, thinly coated white but bright-red at the tip and edges—If there is a complication of the lining membrane, and the nerves of the stomach as well.
   17. It is yellow—It indicates the implication of the liver.
   18. It is tremulous—It represents a complex variety of the nervous form of indigestion and serious implication of a typhoid condition.
10. Facial Expression-The peculiar facial expression assumed by patients under certain diseased conditions is called Thus, mouth breathing with an idiotic expression is characteristic of enlarged tonsils; and ashy pale appearance with a sharp nose and glassy sunken eyes is the facies preceding death. A man with nervous debility wears a bashful look; a pneumonic patient has an anxious expression; a patient with fever and constipation has a dull look, with bluish-red lips. Cholera, ovarian diseases, Bright’s disease, adenoids, liver diseases, tetanus, appendicitis, meningitis. etc., are diseases in which characteristic facies are noticed. These apart, the face very often gives us an idea of the general condition of the patient. Thus, in any acute chest trouble, after a spell of agony, a sudden calm expression is not a good omen.
11. Observe the expression of the eyes:
    1. If the eyes are dilated—irritation of the brain associated with that of stomach and bowels is often indicated.
    2. If they are contracted-it denotes over-irritability of the nerves of sight or irritative inflammatory tendency.
    3. They are languid-resulting from over-loaded stomach or heavy and indigestible food in the stomach, with or without general debility.
    4. If the sight is distorted-it may denote sympathetic affection of the brain as a consequence of irritation of the stomach and bowels as in the case of children having worms.
    5. If the expression is staring-it forebodes delirium.
    6. Eyes are sunken or retracted-when general debility is present.
    7. When the eyes are pearly white—chlorosis is indicated; but a yellow tinge is indicative of jaundice.
    8. If the eyes are prominent or protruding, or gluttering or red-Congestion of the brain or diseases of the heart is indicated.
12. Attend to the condition of the Skin. In fever, it is hot, dry and rough. With the decline of fever, the skin should be moist. Local sweats (as opposed to sweat all over the body) indicates nervous depression and low inflammation beneath the area. Sweat after acute fevers indicates the amelioration of the symptoms; but sweat at night following chronic fevers is indicative of phthisis. The absence of sweat, when the temperature declines in inflammatory and pernicious fever, is of bad omen. Sudden and copious sweating is of grave prognostic omen. The extremities feel cold and look pale before and during the shivering (or rigor) stage of malaria.
13. Notice if there is vomiting or hiccough—Vomiting and nausea are met with in diseases of digestive tract, in injuries to head or in diseases attended with inflammation inside the skull cavity, and in female diseases. Hiccough is due to worms, dysentery, inflammation of the liver, defective function of the urinary organs (kidneys), inflammations of stomach.
14. Pain as an indication of disease should next receive attention. If the pain is localized and the part is hot to touch and tender on pressure, it is If the pain increases on movement, it is muscular. Pain is oftentimes referred to distant parts; in cases of pain in the heart (called angina or breast pang), it is referred to the left arm; in case of liver, to the right shoulder; in case of urinary bladder, to the tip of the penis (male organ); in case of hip-joint, to the knee- joint.
15. Carefully examine the chest It contains the heart in the middle and the two lungs on either side. We have dealt with these organs in their respective places. The best places where to listen for diagnosing the condition of the heart are (a) at a spot 1/3 inch to the inside and 3/4 inch below the left nipple; (b) at places where the 2nd rib joins the breast-bone on the left and on the right side, and (c) at about the centre of the breast-bone.

The chest is to be examined by four means—inspection, hammering (percussion), touch and by the aid of the stethoscope. By ‘Inspection’ we mean a very accurate and keen seriatim observation of the bared chest in natural and sufficient light, the patient enjoying an easy posture. By these means we can detect irregularities of movements of the different parts of the chest-wall—in its qualities, in shape and form and external structural defects. For example, in phthisis or consumption, the portion of chest usually affected is that below one of the collar bones. If a phthisical patient is made to breathe deeply the affected side will not heave so well or so easily as the sound side. Again, in the disease called pleurisy, fluid may accumulate in one side or part of chest; that part will move but little and will look full and bulging.

The next method of examining the chest is by touching it or by ‘palpation’ To do this, lay your palms alternating on each side of the chest, and ask the patient at first to take deep breath and then to pronounce distinctly in words 999. The chest-walls in health are good conductors of sound. If the chest is sound, a very fine vibratory thrill will be experienced by your palms on the patient’s taking a deep breath; and each time he utters 999, you will experience distinct vibrations under your palms. In certain diseases (like pleurisy) these are dulled or not felt at all; in others (as in phthisis), they are exaggerated. So that, during palpation, put your palms alternately on either side of patient’s chest and as far as possible of the corresponding portions of the chest-walls and notice where the thrill (technically called ‘fremitus’) is increased and where it is diminished.

In doing the ‘percussion’ or hammering of the chest- wall, press your left hand fingers between the ribs and with the tip of your right index, middle or right finger or one or more of them, gently hammer on the back of your left- hand fingers. If the hammering stroke is done from the wrist, the stroke will be light and the patient will feel no pain, if however, it is from the elbow, it is likely to be hard and to hurt the patient. This percussion tells us two things: it gives us the sense of elasticity that particular portion of the chest-wall possesses; and it elicites different pitches of sound and thereby tells us the condition of the lungs below. Percussion over a hollow area where lung-tissue has been replaced by fibres gives a dull note.

Auscultation i.e., the hearing of chest-sound by means of the instrument called stethoscope. There are several varieties of it, some of which magnify minute sounds (phonendoscopes). To use the ‘stethoscope’ properly, one must practise for a long time on healthy chest of young persons and children—listening to different portions of them, in order to get thoroughly familiar with the sounds heard in health in different parts of the chest. Having got familiar, it will be easy to detect abnormalities.

Instead of going into elaborate details, we give below the results of examination of chest in a tabular form

While Inspecting note —

1. Shape of Chest—
   1. It may be conical.
   2. Flat—especially in its front and upper part.
   3. Scapulae (or wing bones) may stand out.
2. Freqency of breathing—Normally, a new-born child breathes 44 times a minute, a child of 5 years 26 times and an adult 18 to 20 times a minute. The ratio between the number of pulse-beats in a minute and the respirations per minute is expressed—R P 1 4.
   Slow breathing—indicates shock, collapse, brain- mischief.
   Quick breathing—indicates fever, lung-diseases, excitement, throat trouble.
   Sighing breathing—indicates heart-disease, shock, collapse, brain-mischief.
3. Bulging or retraction of any portion—Bulging occurs when fluid accumulates inside the chest; retraction, when a chronic pleuristic mischief had occurred.
4. Difficulty of breathing—Dyspnoea or Orthopnoea.

By palpation try to ascertain if there is—

1. Friction—indicating pleurisy.
2. Increase vibration—indicating either Pneumonia or Phthisis (with cavity).
3. Something like the purring of a cat—indicating asthma.

By percussion ascertain if any portion of chest is— Dull in note. This means there is either fluid below or that the part is temporarily devoid of air (as in pneumonia or phthisis) or that the pleura has got thickened.

Increase in pitch indicates

1. Air-containing cavity (chronic asthma, phthisis).
2. Solidified (and therefore useless) portion of lungs immediately surrounding air-cells (phthisis).

By Auscultations:

1. Breathing appears to be
   1. Loud-pitched—indicating pneumonia or phthisis or asthma or bronchitis.
   2. Low-pitched or somewhat indistinct—due to extreme weakness, emphysema, or obstruction in air-passages.
2. Abnormal sounds are heard. These may be
   1. Crepitations or fine sounds such as are produced by rubbing hairs together or when fine grains of salt are thrown into the fire. They indicate that the air-cells and small tubes (bronchioles) are full of viscid mucus, as in pneumonia or bronchitis.
   2. Rhonchi—e., musical pipping sounds. They indicate swelling of or presence of mucus in fine air-tubes (bronchioles).
   3. Rales—are non-musical bubbling sounds produced by air passing through viscid liquid.
3. Cough also signifies various manifestations which should not he neglected at all. It points to various derangements according to the conditions which precede, accompany or follow them or by which they are brought on.

Short dry cough, with watering of the eyes and frequent sneezing usually foretells the advent of measles.

Chronic dry cough with difficulty in breathing sometimes associated with stitches, pain in chest, indicates tubercular affections.

Painful cough with feverishness represents the incipient inflammation of the lungs.

Chronic loose cough foretokens chronic bronchitis.

In case of a predisposition to cough arising from excitement, coughing, speaking, rapid motion or exertion, a tendency to organic affection of the lungs is indicated.

17. Examine the stool (faeces). The following characters of stools indicate roughly the disease or conditions mentioned against each. Thus, the stool may be—

Acid smelling—from decomposition of undigested food inside intestines.

Alkaline—decomposed stool.

Brown coloured—natural.

Black coloured—from taking bismuth, iron or charcoal.

Bloody—from piles, ulceration, fissures or fistula; owing to dysentery; cancer of rectum.

Clay coloured—from inspissated bile (due to faulty liver action).

Curds present— (curds of milk found in children) from over-drinking of milk.

Frothy—in diarrhoea or dysentery with much wind accumulation.

Greenish—owing to contents of intestines having been hurried through. In children altered blood appears in green colour.

Mucous—in dysentery; thread worms; rickets (in children); taking overdose of arsenic; bad constipation; from fistula; cancer of rectum.

Pale-coloured— (see white).

Pea-soup-like—in typhoid fever.

Pus present—in dysentery, ulceration of bowels, ruptured abscess inside abdomen.

Slimy— (see mucous).

Sloughs in stools—in typhoid fever, dysentery.

Tarry—from bleeding high up inside the bowels.

White coloured—from obstruction to flow of bile; diseases of pancreas; Sprue.

18. Examine the Urine—The urine often signifies the conditions of the patient in acute or chronic cases. In a healthy state, urine should be pale, bright-yellow or straw-coloured precipitating no sediment and having no offensive smell. A healthy adult passes about a litre and a half of urine in 24 hours. Roughly speaking in hot weather, when one perspires freely, the quantity of urine is less; it is more in rainy season and in winter and during large potations. Severe diarrhoea causes diminished secretions of urine. The reaction of normal urine is acid. The reaction is intensely acid in fevers, gout, rheumatism, chronic Bright’s disease, diabetes, etc. An alkaline reaction represents the presence of debility, anaemia, frequent vomiting. A white deposit in urine immediately noticed after passing urine indicates phosphates; a brick-dust sediment in high coloured urine indicates ureas. A urine that is foetid and ammoniacal-smelling and is at the same time slimy and alkaline in reaction, indicates inflammation of the bladder. Urine that is acid and contains slimy deposit perhaps contains pus. A urine that is scanty and has smoky colour or greenish colour indicates inflammation of the kidneys. A black urine indicates very bad kidney-inflammation or in profuse vomiting and purging.

A sudden check of perspiration will often cause copious and pale urine; relaxation of the bowels, purgatives or profuse perspiration, a darker and more scanty discharge. Certain food will cause the urine, to be offensive; other substances will give it a bright golden-yellow colour. Amongst females a degree of sediment is not always uncommon, nor it is unhealthy.

When passing of urine is painful it may be caused from inflammation or irritability of passage, bladder or kidneys. In case of the inflammation of the bladder, it will always be accompanied with fever, hard pulse, and pain at the bottom of the bowels. If the pain arises from inflammation and irritation of the urinary passage, it will be associated with scalding discharge, matter being present or absent. If the pain results from the affections of kidneys, the urine will be hot and pain felt chiefly in loins and back. If it arises from spasm of the bladder, frequent urging may cause but total inability.