PULSE Literal meaning of ‘pulse’ is a discontinuous event (pulse polio, pulsatile etc.) DEFINITION OF ARTERIAL PULSE Alternate expansion and recoiling of a systemic arterial wall due to transmission of pressure wave along the systemic arterial tree due to ventricular systole and diastole. - Arterial pulse not due to blood flow (speed 0.5 meter/sec), but due to transmission of pressure waves (6-10 meter/sec). Importance of taking arterial pulse = To know ~ 1. Condition of heart 2. Circulatory state 3. Condition of blood vessel 4, Autonomic activity 5. Mental state of subject 6. State of body metabolism & temperature Sites of taking pulse & utility (from above downward)- 1. Carotid artery (innerside of sternomastoid) > identification of heart sound 2. Brachial artery (medial to biceps brachii tendon) ~> during BP examination 3. Radial artery (over lower end of radial bone) > usual pulse examination 4, Femoral artery (below inguinal ligament) > during femoral arterial, venous blood taking) 5. Popliteal artery (knee bent, both thumb of examiner over patella, finger pushed to popliteal fossa) 6. Arteralis dorsalis pedes / posterior tibial artery > to know peripheral arterial diseases Methods of pulse measurement — 1. Digital (Tridigital) 2. Instrumental (Dudgen’s Sphygmograph, Students Physiograph) EXAMINATION OF RADIAL PULSE — Why radial artery is chosen — 1. Located at exposed part 2. Lies over hard surface (radius) Procedure. ‘© Preconditions ~ subject sitting or supine position / physical & mental rest for 5-10 min / explain the procedure * Position of hand of subject — forearm semi-prone / wrist semi-flexed © Examiner use 3 finger (index, middle finger& ring) and feel the radial artery of subject by pulp of tip of fingers (Tridigital) * Pulse rate counted over 1 minute, Points to be noted - 1. Rate 2. Rhythm 3. Volume 4. Condition of arterial wall 5. Delay 1. Rate Normal - 60-100/minute (average 72 / min) Tachycardia — > 100/minCause- Physiological - exercise /after food / anger / pregnancy Pathological - fever / infection / anaemia / thyrotoxicosis /heart failure / acute fluid loss Bradycardia ~ < 60 /min Cause— physiological sleeping / athelate / old age Pathological -- myxoedema / t intracranial pressure / obstructive jaundice Relative tachycardia — in Tuberculosis Relative bradycardia — in typhoid (Normally per 1% temperature rise cause rise of pulse rate 10 /min. here more increase and decrease respectively) 2. Rhythm Types ~ 1. Regular 2.Irregular ~ regularly irregular — In some type heart block (eg. 2:1 heart block) Irregularly irregular ~ In atrial fibrillation 3. Volume Itis the amplitude of expansion of pulse wave. Types ~ 1. Low volume pulse (pulsus parvus) ~ Aortic Stenosis / pericardial effusion / acute fui loss(diarrhea, hee) 2.High volume pulse (pulsus magnus) ~ Aortic cegurgitation/ thyrotoxicosis/ anaemia/ fever 4. Condition of arterial wall — Determined by — + By proximal finger (finger toward heart) radial artery is pressed and obliterated. * By distal finger squeezing the blood to periphery and then pressed to prevent back flow * By middle finger wall of empty artery is felt by rolling it against radius Normal artery cannot be felt or just palpable In Atherosclerosis & calcification in old age itis cord lke Delay Radio-radial delay / radio- femoral delay Normally no delay, delay may be present in coarctation of aorta Reporting of student ( after complete 1 minute examination of Radial pulse): 1. Rate - /min 2. Rhythm - regular 3. Volume - moderate 4. Condition of arterial wall — just palpable 5. No radio-radial delay 6. Radio-femoral delay examination not done. Normal pulse wave 1 Percussion wave or Anacrotic limb — sharp ascending limb/ due to Rapid ejection phase of ventricular systole 2. Catacrotic limb -- descending limb, upto dicrotic notch due to Slow ejection phase Tidal wave - pre-dicrotic wave/ due to elasticity of aorta 4. Dicrotic notch — negative wave/ due to recoil of elastic aorta blood momentarily sweep back toward heart 5. Dicrotic wave - positive wave/ due to closure of aortic valve blood thrown back to aorta So upto dicrotic notch systole then diastole‘Anacroti Puls (Parvus et Tardu eee Wale Hane Pl swore TH | ats Hames Pie ‘low apt pu [paws with 2 vey ie La tonsa deta ABNORMAL PULSES 1. NORMAL PULSE - catacrotic pulse 2. ANACROTIC PULSE (ANADIACROTIC PULSE) ~ notch at ascending limb (two upbeat)/slow rise, wide pulse due to obstructive outflow. eg. Aortic stenosis 3. DICROTIC PULSE - twice beating pulse /diacrotic wave large due to low peripheral resistance. eg. ‘Typhoid fever 4, WATER HAMMER PULSE (COLLAPSING PULSE/ CORRIGAN PULSE) — = Sharp rise and fall of pressure wave. = Dicrotic notch absent = Sharp rise > due to t blood volume(? EDV) - Sharp fall > due to collapse of pulse as — 1. Diastolic run-off of blood to left ventricle 2. Rapid run-off of blood into periphery due to 1 systemic vascular resistance ~ eg. Aortic regurgitation / patent ductus arteriosus / severe anaemia / thyrotoxicosis, Procedure > It is better felt when hand suddenly raised over the head and pulse is felt by palm of the examiner after grasping the wrist of the subject. ‘his procedure cause more return of blood to heart through incompetent valve. 5, PULSUS PARADOXUS — itis misnomer as itis due to accentuation of normal phenomenon - normally volume of pulse decreases in inspiration and decreases with expiration. Here accentuation occurs. ~ eg. Constrictive pericarditis / pericardial effusion / acute severe bronchial asthma Explanation ~ a. inspiration > T negative intra thorasic pressure > pool of blood in pulmonary artery/ vein > V heart filling > 4 stroke volume. b. _inspiration>7 intra-pericardial pressure due pressure by inflated lung > 4 venous return 1 stroke volume ©. in pericardial effusion /constrictive pericarditis->¥- heart filling due to restriction of expansion > 4 stroke volume. d. in acute severe bronchial asthama -> T inspiratory effort-> more negative intrathorasic pressure > 1 venous return > 1-Istroke volume. Paradox is present > in severe cases heart beat is present but pulse is absent. 6. PULSUS ALTERNANS ~ alternate high and fow volume pulse. eg. Left ventricular failure. 7. PULSUS DEFICIT - difference between pulse rate and heart rate. eg. Atrial fibrillation 8, PULSUS BISFERENCE -- combination of the low rising pulse (anacrotic pulse) and collapsing pulse. eg. Combined aortic stenosis and aortic regurgitationBLOOD PRESSURE DEFINITION - lateral wall pressure exerted by the flowing blood on wall of artery. MEASUREMENT ~ 1. Direct method ~ a canula is inserted in a vessel and connected to a manometer. Use ~a) research work b) cardiac & arterial catheterization. 2. Indirect method ~ by sphygmomanometer ( Brachial, femoral artery taken), 3 methods ~ a) Palpatory Method b) Auscultatory Method ) Oscillatory Method Apparatuses 1. Stethoscope 2._ Sphygmomanometer Eanes = 5 “ig appraimately ‘40 16ers lng) Parts of stethoscope Parts of sphygmomanometer_| Measurement of Blood pressure Stethoscope Introduced by Laennec in 1819. Korotkoff used for BP recording in 1905. 3parts— 1. Chest piece or Head ~ two end piece—bell & diaphragm Bell - smooth so little magnification but no distortion of sound / detect low pitched sound (fetal heart sound, Mitral Stenosis) Diaphragm ~ internally serrated so more magnification of sound but distortion also present / detect high pitched Sound (breath sound, kortkoff sound) 2. Rubber tube ~ inner diameter 3 mm. 3. Ear frame - two curved metallic tube / upper end curved forward to fit external auditory canal. Sphygmomanometer Parts— 1. Mercury manometer — Fitted in the lid of instrument. It has two limbs is the reservoir (broad & short) of mercury connected to the cuff and other is graduated glass tube Graduation 0-300 marking, 2mmHg gap, even number marking, 2. Cuff (Riva-Rocci cuff)- Cuff is enclosed in a cloth covering One end connected with mercury reservoir & other end connected with a rubber bulb. Size —In adult 24x12 em<8 yrs ~- 16x8.cm (width of cuff should be 20% more than diameter of arm) <4 yrs ~10x5 cm <1yr ~5x2.5cm_ (for leg width is 20 em or 8 inch) 3. Rubber bulb — = Oval shaped rubber bulb, - Aone way valve at its free end and a leak valve with a knurled screw at the junction with tube. Aneroid manometer — calibrated dial replace mercury manometer. Procedure — + Precondition ~ subject supine or sitting / 5-10 min physical and mental rest / procedure explained. = Wrapping of cuff ~ middle of the cuff over the brachial artery lower end of the cuff 3 cm above the cubital fossa Not too loose not too tight (2 finger should pass) ~-cuff should be at the level of the heart. PALPATORY METHOD. Procedure ~ palpate radial artery of subject at wrist by three finger. - Inflate the cuff slowly by rubber bulb until pulsation disappear. + _ Raise pressure of bulb another 30-40 mmHg. - Open the leak valve of bulb and deflate cuff slowly. - Note the reappearance of pulse (usually at the same level of disappearance), + Pressure at which pulse is first felt is the systolic pressure. - _ Breadingis taken and average done and compared on both side. Reappearance of radial pulse is more distinct than disappearance so easier to detect, Advantage of palpatory method ~ 1. Helps to avoid missing auscultatory gap. 2. Stethoscope not required. 3. Less experienced personnel can do it. Disadvantage of palpatory method - 1. Diastolic BP cannot br measured. 2. Lack of accuracy (measured SBP is 4-6 mmHg lower as first 2-3 beats are feeble so may be missed and also transit time of blood from brachial artery to radial artery. AUSCULTATORY METHOD — Procedure — palpate the brachial artery just medial to biceps tendon at cubital fossa and mark it. ~ Record SBP by palpatory method first. = _ Raise pressure of cuff 30-40 mmHg above the palpatory level. - Place the diaphragm of stethoscope lightly on brachial artery. - Now deflate the cuff slowly (2-3 mmHg/sec) and at a range of pressure different types of sounds (korotkoff sound) heard - Note appearance, disappearance and change of quality of sound. KOROTKOFF SOUNDS — Aseries of different frequency & intensity sound due to different types of turbulent flow, heard over brachial artery below the cuff during measurement of BP are called Korotkoff sounds. Phases - (mnemonic TMGM) 1. PHASE |~ Tapping sound (T)PHASEII - Murmurish sound (M) PHASEIII - Gong sound (6), louder, rocking, banging type. PHASE IV ~ Muffled sound (M) 5. PHASE V - Disappearance of sound. ‘SBP= appearance of 1" sound DBP ~ disappearance of all sounds ‘* Muffling sound taken as DBP in ~ adult after exercise / children / thyrotoxicosis, * In aortic stenosis Korotkoff sound may continue right down to the zero level. ron 150 mm Hg—>120 mm Hg——»80 mm Hg——>0 mm Hg Law Phase! [Phase li Phase Ill_|Phase IV|_Phase V Faint tapping | Swishing [Loud knocking| Muttied | Silence AUSCULTATORY GAP (KOROTKOFF GAP / SILENT GAP) — Definition -- In severely hypertensive patient sometimes during measurement of BP by auscultatory method, after a few tapping sound no sound is heard for a variable period and then sound is heard again. This period of silence is called auscultatory gap. For example, someone has BP 200/100 mmHg. In this case sounds appear at 200 mmHg and persist up to 190 mmbg then no sound is heard up to 150 mmHg. Then sounds appear and disappear at 100 mmHg. Now, if the examiner arbitrarily increases cuff pressure 160 mmHg and then deflate the cuff. He will mistake SBP as 150 mmHg and interpret BP as 150/100 mmbig. This will cause great change treatment plan. To avoid this palpatory method is mandatory before auscultatory method to know SBP. Advantages of auscultatory method — 1. Gives accurate value of SBP. 2. DBP can be recorded. Disadvantage of auscultatory method ~ 1. May miss auscultatory gap. 2. Experienced personnel are required. OSCILLOMETRIC METHOD ~ 8p recorded seeing oscillation of mercury column or hand of dial device. ‘Some relevant points 1. Systolic Blood pressure (SBP) ~ maximum BP produced during cardiac cycle (systole) Normal value ~ 100-140 mmHg Significance ~ reflects cardiac output. 2. Diastolic Blood Pressure (DBP) ~ minimum BP found during cardiac cycle (diastole) Normal value - 60-90 mmHg Significance - reflects peripheral resistance (elasticity of vessel & viscosity of blood -DBP is more important than SBP as SBP reached momentarily but DBP is exerted throughout day on vascular system. 3. Pulse pressure (PP) = SBP - DBP SBP : DBP : PP=3: 2:1 (normally) 4, Mean arterial pressure (MAP) = DBP + 1/3 PP (itis more toward DBP as diastole is longer than systole) Significance - MAP is determinant of tissue perfusion. s. wil EsSome people have higher BP reading in the clinician's chamber (Fearing of white-aproned doctor). To overcome this 5-10 min physical and mental rest is required before checking BP. 6. Left arm is preferred as left brachial artery unlike right is a continuation of left subclavian artery, @ direct branch of aorta, So BP is more accurate. 7. Prolonged inflation of cuff may cause reflex vasoconstriction and false high BP. APPLIED — Hypertension —t 8p According to JNC-8 (Joint National Committee) - Blood pressure classification | SBP (mmHg) DBP (mmHg) normal = 120 and < 80, Pre-hypertension 120-139 (or 80-89) ‘Stage | hypertension 140-159 or 90- 99) ‘Stage II hypertension > 160 or > 100 Isolated systolic hypertension | > 140 ‘and < 90 Hypertension can be classified into ~ 1. Essential or primary hypertension ~ no definite cause (90% cases) 2. Secondary hypertension - caused by other diseases ~ a) Renal disease - glomerulonephritis, renal artery stenosis. b) Endocrine ~ Cushing syndrome, pheochromocytoma, connss disease. ) Congenital heart disease ~ coarctation of aorta, 4) Iatrogenic - oral contraceptives. Hypotension — | BP (SBP < 100 mmHg &/or DBP < 60 mmHg) Causes a) acute hemorrhage b) severe diarrhea / vomiting ¢) iatrogenic — excessive diuretic use. Factors affecting BP -- (BP = CO x PR) Factors affecting cardiac output ~ 1. Preload 2. After load 3. Inotropic state Factors affecting peripheral resistance ~ 1. Diameter of the blood vessel 2. Viscosity of blood EFFECT OF POSTURE ON BP AND HEART RATE ‘Two types of effect — 1. Effects on immediate standing 2. Effects on prolonged standing.1. Effects on immediate standing — (On immediate standing from supine > venous pooling of blood at leg (250-300 mi) > 4 SBP (10-15 mmHg) Compensation — within 10-15 seconds baroreceptor mechanism restore BP . Within 15-30 sec SBP returns to normal or slightly elevated from supine SBP but DBP elevated and tachycardia persists as vasoconstriction increase peripheral resistance. 2. Effects on prolonged standing — On prolonged standing > venous pool > 500 ml at lower part > plasma filtered out to tissue space > LL venous return > 4 cardiac output (upto 40%) 211 BP > cerebral ischemia > fainting Compensation — all compensatory mechanisms (Baroreceptor, sympathetic etc.) becomes less effective. Procedure ~ after rest and relax for 5 min check BP and pulse rate in supine posture (palpatory & auscultatory) -without removing cuff ask the subject stand up and check BP and pulse rate immediately (within 15 sec) check 2,5 and 10 minute after standing Physiologic significance - this change reflects integrity of autonomic nervous system, Postural (orthostatic) hypotension — here fall of S8P > 20 mmHg & DBP >10 mmHg on immediate standing Causes ~ Autonomic neuropathy (diabetes), primary hyperaldosteronism, on sympatholytic drugs EFFECTS OF GRAVITY ON BP — ‘+ Pressure of any artery and vein increases below the level of the heart and decreases above the level of heart Degree of this effect is 0.77 mmHg / cm. ‘If MAP at the level of heart is 100 mmHg, MAP 100 cm below heart level is (100 + 100X0.77) = 177 mmHg ‘+ Procedure ~ BP is recorded keeping arm at, above and below the level of the heart. EFFECT OF EXERCISE ON BP AND HEART RATE Degree of exercise — according to 1. Rate of 02 consumption 2. Work done 3. Rate of rise of heart rate, 3 types ~ Mild exercise ~ 02 consumption > 0.5 -1liter/ min -Work done -> 150-350 watts ~ Rise of heart rate > 25% Moderate exercise ~ 02 consumption > 1-2 liter/ min ~ Work done > 350-550 watts - Rise of heart rate > 50% Severe exercise -- 02 consumption > > 2 liter/ min = Work done > > 550 watts - Rise of heart rate > 75-100 % Types of exercise ~ 1. Isotonic 2. Isometric ISOTONIC EXERCISE — changes of muscle length (walking, jogging, running) Effects ~ heart rate increases proportionately with degree of exercise - cardiac output increase markedly - SBP tT but DBP 7 with mild exercise, slight | with moderate exercise, always J severe exercise Mechanism — ‘T spp < T EF € Isotonic exercise > (52 sympathetic stimulation to the exercising muscle + aProduction of CO2, K+, H+, Adenosine in muscle > vasodilatation > 1 PR > LDBP ISOMETRIC EXERCISE ~ no change in the length of the muscle (pushing against the wall) Effects — heart rate rises due to both decrease vagal tone and increase sympathetic tone. = Stroke volume changes relatively little. = Both SBP & DBP T sharply Mechanism — 1 sap € 7 EF © Isometric exercise > T muscle tone > vasoconstriction due to compression by muscle >T pep Procedure ~ - Record BP & pulse rate of subject after 5 minute rest. - Ask him for spot jogging for a period of 5 minute. - Record pulse rate & BP immediately, 2,4,6.8 and 10 minute after exercise.EXAMINATION OF CRANIAL NERVE OLFACTORY NERVE (I) jensory — Inspection - - See any growth, obstruction by foreign body and also condition of nasal mucosa. Test proper ~ Requirement > vial of peppermint/vanilla/coffee/almond oil/alcohol etc. Procedure: = Subject sitted comfortably + Make sure nostrils are clear - Ask to close eyes and one nostril + Askif correctly perceive smell from vial. ~ Repeat bilaterally and compare Olfactory pathway — Olfactory receptor cells > olfactory Nerve (axons of receptor cells) -> (via cribriform plate) olfactory bulb {glomerular synapse] > 2” order of neuron (axons of mitral & tufted cell] form olfactory tract > medial & lateral olfactory stria > primary olfactory cortex. APPLIED Anosmia (no smell) - 1. Bilateral - common cold / fracture cribriform plate / atrophic rhinitis 2. Unilateral - tumor at olfactory bulb or frontal lobe Parosmia (bad smell) ~ mental disorder / head injury Hyperosmia— adrenal insufficiency Hallucination of smell (subject perceive smell in absence of smell) — in some epilepsy OPTIC NERVE (I) — sensory HISTORY ~ H/0 change of eve sight. EXAMINATION ~ 1. Acuity of vision 2. Field of vision. 3. Color vision. Acuity of vision (resol wer of eyes) DEFINITION ~ ability to see the details and contours of object clearly both near and distant. EXPLANATION — ability of eyes to recognize two point sources of light as separate rather one. Two points form an angle (visual angle) of 1 minute of arc at nodal point (NP). (NP =Middle point of lens > no light refraction)- 1 minute visual angle correspond to a 4.5 1m at retina, Foveal cone cell diameter is 1.5 jum. so 3 cone distance (4.5.1m) and middle cone is unstimulated, This causes separation of two points. 60 metres 20 40 60 a0 100 200 feet Distance EXAMINATION ~ ant vision — Snellen’s chart (Hermann Snell -Dutch ophthalmologist) - Letters are depicted on 2 card board in 7-8 lines of different fonts. Topmost line can be read by normal subject at a distance of 60 meter and subsequent lines at 36, 24, 18, 12, 9, 6, S meters respectively (letters are so sized that at specific distance produce 5 minute and two limb produce 1 minute angle at nodal point) ~ Position of subject ~ 6 meter or 20 ft from chart. ~ Subject asked to close one eye gently and read the chart with the other eyes and done bilaterally with and without spectacle Interpretation VA = d/0 (d =distance at which letters are read, D =distance at which letter can be read) VA= 6/60 means person can see only 1" (topmost) line If person unable to see even 1* line, he is moved toward chart 1 meter in each step. VA 5/60, 4/60, 3/60, 2/60, 1/60. If person unable to see 1° line even at 1 meter distance, then tests are done ~ 1, Counting of finger (CF). 2. Hand movement (HM). 3. Projection of ray (PR). 4. Perception of light (PL) Other charts ~ 1) Landolt Ring Chart 2) E -Chart 3) Animal Chart (in children} Near vision - Jaegers chart ( Edward Jaeger), letters of various sizes on Printer point system or newspaper print -chart read at 10-12 inch distance - Previously pointed as J now as N. smallest point N-5, largest N-36. FAR POINT -farest point from eye, object can be seen clearly = 6 meters. NEAR POINT ~ nearest point from eye object can be seen cleariy = 10 cm (at age 10 yrs).aco onoCcoe coo00 a attack, they twemod to yidd a9co2000 to th weight of the Roman 0S 6 ame gore, thy san, by «sal | } = ) Snellen chart Landolt € chart Jaeger chart FACTORS AFFECTING ACUITY OF VISION — 1. Object factor ~ a) illumination of surface b) Size of object €) Distance of object 4d) Color of object (white more) e) Brightness of object f] Duration of exposure 2. Subject factor ~ a) refractive error ~ if image is blurred, VA decreases. b) Retinal factor - VA maximum at fovea centralis. APPLIED 1. Children VA < 6/9 should sent for refraction. 2. Blindness - according to WHO, blindness is defined as visual acuity of less than 3/60, or a corresponding visual field loss to less than 10° in the better eye with best possible correction. a) Economic blindness ~ VA 6/60 - 3/60 b) Social blindness ~ VA 3/60 - 1/60 ©) Legal blindness - VA 1/60-PL d) Total blindness ~ no light perception 3. Error of refractions a) Myopia (short sightedness) ~ distant object cannot be seen clearly. rays focus in front of retina. ~ eyeball longer ~ concave lens required for correction. b) Hypermetropia (long sightedness) -near objects are not seen clearly. ~-rays focus behind the retina. ~ convex lens required for correction.¢)_ Presbyopia — in old age, lens harden, failure to adjust visual apparatus ~-cannot see clearly near objects biconvex lens are required. -- occurs early in hypermetropia. FIELD OF VISION DEFINITION — a cone of space with its apex at the eye, which is seen by subject. ‘© It assesses function of central and peripheral retina. ‘* Peripheral field is widest for white. Then blue > red > green (lowest) © Allregions of retina tested except macula (fovea centralis) ‘Physiological blind spot is optic disc (no rod and cones ~ physiological scotoma) ‘Whole field subdivided into ~ 1. Uniocular field 2. Binocular field 3. Mono-ocular segment outside binocular field. © Field of vision is ~ 50° upper, 60° medial, 70° lower, 100° lateral. Supra-orbital ridge and nasal bridge obstruct field. Visual pathway - Retina optic Nv. > optic chiasma > optic tract > LGB > optic radiation > primary visual cortex. Factors affecting visual field ~ 1. Visual acuity 2, Size of object 3. Color of object (W>B>R>6) 4, Brightness of object 5, Color of object Methods of examination 1. Confrontation test — Comparative test (with examiner supposing his field of vision is normal) ~ Distance is 3 ft (handshake distance) between subject and examiner. ~ eye same level of both, look each other's confronting eyes (e.g. examiners left eye wit ~ no head movement. subject's right eye) ~ Test one eye and both close other eye with one finger gently placed from side to keep field of vision unhindered. Confrontation test ~ bring the moving index finger of examiner from periphery to center in the mid-plane between subject and examiner at all fields and notice when itis visible by subject. ~ examine both eyes. 2. Lister / Goldman's perimeter — Perimetry — Definition - the method of charting the field of vision is called perimetry. Perimeter — types ~ priestly: Smith's perimeter Lister/ Goldman's perimeterbr Stand with object holder 2. Source of light Adjustable chin rest Spring lock Metal arc Chart marker Chart holding plate Nama Parts ~ 1. Stand ~a heavy stand, on which a metal arciis fitted on a pivot, 2. Metal arc~a half circle shaped metal arc, can be rotated in any meridian, One arm has a scale of 0- 90° at 10° intervals on its convex surface. Test object of various size and colour can be fitted in the groove of the arm. When test object moves @ pin on the back of the apparatus moves correspondingly. On the other end of the arm a source of light is fitted. 3. Chin rest ~to keep head steady. 4. Chart - fitted on the back of the perimeter. On which field of vision is to be plotted. Center of the chart correspond with visual axis. Concentric circle of 0 - 90° at 10° intervals present. Meridian is divided at 15° intervals. Normal peripheral field of vision for two eyes and blind spots are printed on the chart for comparison. Procedure — 1. Explain the procedure to the subject. Remove glass if any. Fix a chart, Ask to rest chin (for right eye rest chin on left chin rest). Ask to cover left eye with hand, 2. Arrange the arc with concavity toward subject. Ask to fix the eye of subject at center. Bring a white ‘Smm sized object from periphery to center at a particular meridian. 3. Ask the subject say ‘yes’ as soon as object comes into view. Now strike the chart holder against pin . then slowly move the object toward center to find out blind spot or scotoma. 4, Test all meridian at 30° intervals. 5. To find blind spot, test at temporal meridian (usually 100° meridian). Disappearance of object at 20° and again reappearance at 5°. (Blind spot situated about 15° lateral to the fixation point). Observation - 1. Observe the obtained field of vision and compare with normal field. 2. Note the size and site of blind spot 3. Note any presence of scotoma.‘CAUSES A | Optic atrophy, optic neuritis B | Pituitary tumor | Trauma D | Distention of 3 ventricle E | Vascular cause F | Vascular cause G | Vascular one cause ae Lesions in the optic pathway/—] 2.Scotoma — localized loss of field of vision. e.g. glaucoma. COLOUR VISION — Young Helmoltz theory - 3 primary colours - red, green, blue. Examined by ~ 1. Ishihara chart - pseudo-isochromatic (maximum 5-10 sec. for each plate, colour blind patient reads a different number). 2. Lantern test 3. wool-matching test Ishihara chart Ishihara chartApplied — ‘CONE SYSTEM/ PRIMARY COLOUR | CONE PIGMENT COLOUR BLIND | COLOUR WEAKNESS RED ERYTHROLABE PROTANOPIA PROTANOMALY GREEN CHLOROLABE. DUTERANOPIA | DUTERANOMALY, BLUE CYANOLABE TTRITANOPIA TRITANOMALY OTHER EXAMINATIONS— a. Ophthalmoscopy (fundoscopy) ~ direct examination of retina. b. Pupillary reflex (both for optic & oculomotor Nv.) ~ light reflex (direct / indirect), accommodation reflex. Report of the student after examination — Acuity of vision, field of vision and color vision of the subject are within normal limit, so the optic nerve of both side are functioning normally. Oculomotor(Ill), Trochlear(IV), Abducent(VI) Cranial nerve NERVE | TYPE ‘ORIGIN SUPPLY FUNCTION ill | Somatic efferent | 1.0culomotor nucleus (mid | 1. All extra ocular | 1. Movement of eye ball brain) muscles except Parasympathetic LR/SO. efferent 2.Edinger westphal nucleus | 2.Ciliary muscle, | 2. Constriction of pupil. (ewn) sphincter papillae | Light reflex, accommodation reflex. IV | Somaticefferent |Trochlear nucleus (mid | Superior _ oblique | Movement of eye ball. brain) (s04) Vi__| Somatic efferent | Motor nucleus of Vith Nv. | Lateral rectus (UR6) | Movement of eye ball (pons) Extra ocular muscles ~ 1. Levetor palpabrae superioris 2. Superior rectus All muscles supplied 3. Inferior rectus by 31 cranial Nv. 4. Medial rectus Superior oblique by ae Usterel eeu 4°" & lateral rectus by 6. Superior oblique 6 cranial Nv. 7. Inferior oblique 8. Mullars muscle Mullars muscle & itor pupillae lntra cenlar magaas= supplied by cervical 1. Ciliary muscle sympathetics. 2. Constrictor pupiliae sion male & 3. Dilator pupillae 314 cranial Nv. ALL3. S04 / LRE constrictor pupillae byHISTORY - history of double vision, trauma, family history of diabetes. EXAMINATION — 1. Upper lid - a) ptosis upper lid covers 1/6" (2mm) of cornea. If >2mm itis ptosis. b) Lid retraction, 2. Position of eyeball at rest — squint / exophthalmos / enopthalmos / hypertelorism / conjugate deviation. 3. Pupil ~ Size (normal, dilated or constricted. Dilated may be due to darkness, sympathetic over activity, in 3 nerve palsy. Constricted may be due bright light, pontine hemorrhage etc.) ~-shape and margin (normally circular but may be irregular due to irtis, neurosyphilis). ~Pupillary reflexes. 4. Conjugate Movement of eyeball - IR so Procedure — a) Subject’s both eyes open. No movement of head. Ask to follow moving finger of examiner at 25 em distance b)_'H’ pattern of movement. Start from center to right extreme of subject's visual field then up and down, then again to center and then to left extreme and up and down. For right eye use left index and vice versa, ©) Recti muscles perform movement in the same direction as the name implies. But for oblique muscles movements in opposite direction to that implied by name. i.e. SO > Depression, 10 > elevation 4d) In abducted position, recti are sole elevator or depressor. In adducted position, oblique are sole elevator or depressor. (Explanation - long axis of recti (superior/inferior) makes an angle of about 25° on lateral side with optical axis but oblique muscles make 51° with optical axis on the nasal side.) Intorsion — along the antero-posterior axis movement of eyebell where the superior pole of cornea moves medially. Intortor Muscles are superior rectus & superior oblique. Extorsion — here superior pole of cornea moves laterally. Extortor muscles are inferior rectus & inferior oblique. Functions of extra ocular muscles — ‘Muscle Primary action ‘Secondary action ‘Tertiary action Medial rectus ‘Adduction = Lateral rectus Abduction Superior rectus Elevation Intorsion ‘Abduction Inferior rectus Depression Extortion ‘AbductionSuperior oblique Tntorsion Depression ‘Adduction Inferior oblique Extorsion elevation ‘Adduction Pupillary reflexes - 1. Light reflex —a) direct light reflex b) Indirect or consensual light refiex 2. Accommodation refiex ect light reflex — a) Sufficiently dark room. bb) Subject looking at ceiling / supine position. ©) Narrow beam of pencil torch brought from lateral side (To avoid accommodation reflex) focused on one eye. 4d) Indirect light reflex, brisk constriction of pupil on focused eye. e) Procedure repeated to other eye. Indirect (consensual) light reflex - PATHWAY OF LIGHT REFLEX a) Procedure same like direct light reflex. b) Piece of cardboard or hand placed between eyes ( to prevent entry of direct light) ©) Here constriction of pupil occurs on other eye where light not focused. pathway of light reflex — Retina > optic Nerve > optic chiasma > optic tract > pretectal nucleus > EWN on BOTH SIDE ~>ciliary ganglion > constrictor pupillae. Accommodation reflex — - Adjustment of visual apparatus for near vision. 3 events occur ~1. Convergence of eye ball 2. Constriction of pupil 3. Bulging of anterior surface of lens. Procedure ~ a) Examiner keeps his index finger 10 -15 cm. front of nose of subject. b) Subject asked to look at a distance (infinity). ©) Now asked to look at the tip of the index finger of the examiner suddenly (from distance to near vision). d) Observe 3 events Pathway of accommodation reflex — Generation of afferent impulse -- Distant vision > ciliary muscle relaxed > tension at suspensory ligament ~ lens flattened ~>parallel light focus at retina. Near vision > divergent light not focus at retina > blurred image > afferent impulse goes via optic nerve.Accommodation reflex pathway Afferent impulse travelling via optic Nv. > optic chiasma > optic tract > LGB > optic radiation > primary visual cortex ( area 17) > frontal eye field area ( area 8) > cortical fiber descend through internal capsule. + v v Oculomotor nuclei of both side ‘some cortical fiber synapse with EWN of both side + Medial rectus muscle v Convergence of eyeball ciliary muscle via ciliary ganglia & constrictor pupillae v v Bulging anterior surface of lens pupillary constriction picture Direct light reflex Indirect light reflex ‘Accommodation reflex APPLIED — 1. HORNER SYMDROME ~ occurs in damage of cervical sympathetic fibre Clinical Features ~ pseudotosis (mullar: s muscle paralysis) B Miosis (dilator pupillae paralysis) Mm Anhydrosis B® Enophthalmos 2. ARGYLL-ROBERTSON PUPIL ~ occurs in neurosyphilis (destruction of pretectal nucleus). LR - VE/ AR +E. 3. REVERSE ARGYLL- ROBERTSON PUPIL - occurs in neurosyphilis (area 8 damage). LR +VE / AR -VE. 4. ADIES PUPIL~LR decrease. 5. 3" NERVE PALSY ptosis / squint (laterally deviated) / mydriasis (fixed dilated pupil) / LR, AR lost. 6.4" NERVE PALSY - diplopia on looking downward. 7. 6™ NERVE PALSY - diplopia on looking paralyzed side. Nystagmus Definition - these are rhythmic, involuntary and jerky movements of eyeball when they are fixed on an object. Types — 1. Pendular nystagmus — nystagmus on looking forward. 2. Horizontal nystagmus ~ nystagmus on horizontal eye movement. 3. Vertical nystagmus ~ nystagmus on vertical eye movement + Test done after checking power of extra ocular muscles. Causes ~ 1. Disorder of sensory visual pathway. 2. Vestibular & semicircular canal disorder 3. Cerebellar diseases = nystagmus also seen in blind persons Squint,Non-conjugal movement of eyes (visual axis not meeting at point of fixation). ‘Types ~ 1. Paralytic — acquired /diplopia present. 2. Non-paralytic - present since childhood /diplopia absent. Report of student after examination — 1. There is no ptosis, squint, nystagmus. 2. LR (both direct and indirect) & AR normal on both sides. 3. Movements of eyeball are normal. 4, S03", 4, 6 cranial nerves of subject are normal both sides. TRIGEMINAL NERVE (V) xed nerve - 3 divisions NERVE TPE | SUPPLY V1 | Ophthalmic Sensory Conjunctiva, cornea, lacrimal gland, skin of medial part of nose, upper eye division lids, forehead, scalp as per as vertex, upper part of nasal cavity. V2 | Maxillary Sensory Check, lower eye lid and its conjunctiva, side of nose, upper lip, upper division teeth, upper part of pharynx, major part of soft palate, tonsil. V3 | Mandibular ‘Sensory Lower part of face, lower lip, lower teeth, ear, anterior 2/3" of tongue division (general sensation not taste), temporo-mandibular joint. motor Muscle of mastication (masseter, temporalis, lateral and medial pterygoid), tensor tympani, tensor palate myelohyoid History - any impairment of facial general sensation, difficulties in mastication Examination - Sensory ~ Touch, pain, temperature, two-point discrimination at all three division done bilaterally after closing eyes by cotton wool, pin, hot water- containing test tube, pin compass respectively. Motor -1. Masseter & temporalis ~ ask to clench teeth and note the contraction of muscle by inspection and palpation by placing palm on both side. 2. Pterygoid - 1. Ask for opening the mouth > see jaw is symmetrical or deviated. If deviation > deviation to paralyzed side by action of lateral pterygoid of healthy side. 2. Open jaw against resistance > see power of pterygoid. 3. Ask to protrude lower jaw forward. 4, side by side movement of lower jaw without then with resistance Reflexes & jerks - 1. Corneal reflex ~ afferent 5" / efferent 7® cranial Nerve to both eyes. Procedure — subject asked to see one side and lateral edge of cornea of opposite eye is gently touched by cotton swab ~ blinking of both eyes. (Avoid touching central cornea as it may cause ulceration) 2. Conjunctival reflex — sudden touching of conjunctiva cause blinking of both eyes. 3. Nasal or sneezing reflex — irritation of nasal mucosa cause sneezing, 4. Jaw jerk (maxillary reflex) - both afferent & efferent 5" cranial nerve. Procedure - placing a finger below the lower lip on chin and mouth slightly open. strike over finger by percussing hammer > closing of mouth occur. Normally not present. But present after age SOyrs. Exaggerated in ~ pseudobulbar palsy, UMN lesion of 5 nerve.Report of student after examination -— 1. General sensation of different region of face are normal 2. Corneal and conjunctival reflexes are normal. 3. No deviation of jaw. 4, Muscle of mastication are normal. 5. Jaw jerk normal. 6. So, trigeminal nerve of subject on both sides are normal. Nucleus of Trigeminal nerve ~ Trigeminal nerve supply 1. Principal nucleus of trigeminal nerve — related to touch, proprioception, two point discrimination. 2. Mesencephalic nucleus ~ related to proprioception from temporomandibular joint, mastication muscles. 3. Spinal trigeminal nucleus (extend from pons to 2° cervical segment of spinal cord) ~ related to pain, temperature. 4, Motor nucleus. APPLIED — 1. Lesion at cavernous sinus (THROMBOSIS) cause loss of corneal reflex and forehead sensation (V5). 2. Neoplasm at the base of middle cranial fossa impair one or more branch of trigeminal nerve. FACIAL NERVE (VII) = mainiy motor, small sensory. Types Cell of origin supply Function Motor efferent | Motor nucleus of Vil | Muscles of facial expression (except | Facial expression Nw. lavetor palpabre superioris) stepedius Tympanic reflex Parasympathetic | Superior salivary | Submandibular, sublingual & palatal | Secretomotor nucleus gland lacrimatory nucleus _| Lacrimal gland Lacrimation Special sense | Geniculate ganglia | Anterior 2/3'° of tongue (taste bud) _| Taste sensory) Anterior wall of external auditory canal | Skin sense Mimic fiber — 2 different pathway separated from pyramidal tract (so emotional movement not affected in hemiplegia) arises from thalamus and ends at facial nerve nucleus. These fibers are responsible for emotional movement of face. History — facial deviation, i dribbling of saliva. Examination - Inspection - see facial expression for - widening of palpebral fissure. jeviation of angle of mouth \complete closure of eye of one side, dryness of mouth, loss of taste sensation,~loss of nasolabial fold. Tests — 1. Testing muscles of facial expression and muscle involved ~ a) Ask to look upward ~see wrinkling at forehead, compare both sides (frontal belly of occipitofrontalis). b) Ask to frown — see wrinkling between both eyebrows (corrugator superciliars). 1) Ask to close eyelids - first gently then tightly then against resistance (orbicularis oculi) d) Ask to whistle — (orbicularis oris) e) Ask to blow — (orbicularis oris & buccinators). f) Asked to Show teeth — (zygomaticus major, minor, levator angularis oris) 2) Draw angle of mouth downward - (platysma). Test for orbicularis oris & buccinators Test for orbicularis oris Test for occipitofrontalis Test for platysma test for zygomaticus Test for orbicularis oculi 2. Taste sensation — Procedure ~ ask to close eyes > give substances on protruded tongue (anterior 2/3° ) by dipping glass rods in sugar, salt, vinegar, quinine one after another after rinzinging mouth thoroughly in each type > open eyes and show the cards mentioning SWEET, SALTY, SOUR, BITTER without speaking (as speaking cause salivation and dissolved substance may go posterior 1/3" of tongue). = Quinine is given at last as bitter sense persist for long time. 3. Reflexes ~ a) Corneal reflex. b) Glabellar tap reflex - tapping lightly between eyebrows produces blinking. Normally it goes off wit 5 tap. In UMN lesion it persists throughout. ©) Snout (orbicularis oris) reflex ~ touching of naso-palatine fissure causes puckering movement of lip. -normally absent, if present - UMN lesion. 4. Schirmers (lacrimation) test ~ special blotting paper placed in lower eyelid and removed after 5 minutes. = normally at least 10 mm. will be dampened.APPLIED. UMN of Facial nerve UMN of facial nerve Cortico-nuclear fiber of one side supplies — 1. Both upper and lower part of facial nucleus of opposite side, 2. Only upper part of facial nucleus of same 1 2 Upper part of facial nucleus supplies only facial muscles of upper part of same side. Lower part of facial nucleus supplies only facial muscles of lower part of same side. side. UMIN TYPE FACIAL PALSY TMN TYPE FACIAL PALSY (BELLS PALSY)~ commonest 1. Cause — cortico-nuclear fiber involvement | 1. Cause — idiopathic, viral infection, trauma. {tumor at pons, syringobuibia). 2. Both upper and lower face of same side 2. Only lower face of opposite side affected affected. 3. No involvement of mimic fibers. 3.__No involvement of mimic fibers. 4, Taste sensation is not affected. 4, Taste sensation absent. 5. No atrophy of muscles. 5. Atrophy of the muscles occurs. 6._Snout & glabeliar tap reflexes present. 6._Both reflexes are absent. 2. BELL'S PHENOMENA ~ Eyeball roll upward to compensate failure of eyelid closure (lagopthalmos) when patient attempt to close eyes. In normal subject itis also present. But due to normal eyelid closure we cannot see it. 3, RAMSAY HUNT SYNDROME ~ herpes zoster at geniculate ganglia cause ~ a) LMN type facial palsy. b) Anterior 2/3” of tongue test lost. €) vesicle at external auditory canal. d) hyperacousis due to stapedius paralysis. 4. Bilateral facial nerve palsy- Gulliain Burry Syndrome (G.B. syndrome) Report of students — There is no history suggestive of facial paralysis. So, facial nerve of subject is normal, All muscles of facial expression are examined and found normal bilaterally| ‘There are no abnormalities of salivary and lacrimal secretion. ‘Taste sensation at anterior 2/3" of tongue is normal. Ne Foc re alps UMN & LMIN of facial nerve:VESTIBULE- COCHLEAR NERVE (VIII) —1wo components 1. vestibular nerve 2. Cochlear nerve, nerve: Cells of origin supply Function Vestibular nerve Vestibular ganglion Semicircular canal Dynamic equilibrium labyrinth, Static equilibrium Cochlear nerve Spiral ganglion cochlea hearing A. Test for cochlear nerve — History - any pain, discharge, any deafness, any tinnitus, vertigo. Examination ~ 1. Inspection — see for wax or discharge at external auditory canal. 2. Voice test (whisper test) - conventional voice generally heard at a distance of 10 -12 ft. -examiner makes whispering voice from behind of subject at different distance. 3. Watch test ~ close eyes and other ear. ~ Awrist watch is placed at different distance and note for hearing. ~ If suspected for impairment then tuning fork tests are done. 4. Tuning fork test Vibration of organ of corti produce action potential and thus sound is perceived. ~ Vibration may occur directly by sound passing through external ear (Air conduction). ~ Vibration of may also occur when transmission of vibration occurs from any part of skull (Bone conduction), ‘AIR CONDUCTION or AC (45 sec.): External ear > tympanic membrane > ossicle (malleus, incus, stepes) > round window > cochlea > stimulation of sensory hair cell of organ of corti. BONE CONDUCTION or BC (35 sec.) Vibration at any part of skull > stimulation of bony cochlea -> stimulation of organ of corti (Tuning fork of 256 or 512 Hz is used here. 112 Hz tuning forkis used for sensory or joint vibration). Deafness - two types—1. Conductive deafness 2. Sensory neural deafness. 1. Conductive deafness - when conduction of sound to internal ear affected. Cause ~ pathology of external auditory canal (wax), tympanic membrane (perforation), decrease pressure at middle ear (common cold) ossicle (otoscerosis) 2. Sensory neural (perceptive) deafness - when perception of sound by organ of corti or neural path is defective. Cause ~ pathology at organ of corti or auditory canal a) RINNE’S TEST Procedure ~ Striking tuning fork over hypothener eminence or thigh vibration is produced - Vibrating tuning fork is now placed over mastoid (BC) of subject and asked to raise hand when unable to hear. tuning fork now placed 2-3 cm. away from ear and asked whether he can hear or not and how long, Observation - 1. | normal subject ‘AC (45 sec.) > BC (35 sec.) POSITIVE RINNE 2._| conductive deafness BC> AC, NEGETIVE RINNE 3._| Sensory neural deafness ‘AC > BC (but both low) LOW POSITIVE RINNE 4. [Severe sensory neural | BC> AC (BC by opposite ear) FALSE NEGETIVE RINNE deafness (Dead Labyrinth)b) WEBER TEST ~ Procedure ~ a vibrating fork placed over forehead at midline. - Subject is asked to notice in which ear sound is better heard Observation ~ 1. | Normal subject Equally heard both ear (as if sound centralized at forehead) 2. | Conductive deafness Localized at worse side as masking effect of environmental noise absent at diseased ear 3. [ Sensory neural deafness _| Localized at better side ©) SCHWABACH TEST ~ this test compares the bone conduction of subject with that of the examiner. -after stopping BC of subject, place tuning fork over examiner's mastoid and check for hearing. 4d) AUDIOMETRY - modern test for hearing both for AC &BC. ¢) BRAIN STEM AUDITORY EVOKED POTENTIAL (BAEP) ~ accurate method to differentiate organic and functional deafness also exact site of pathology. B) Test for vestibular nerve — History — presence of any vertigo, tinnitus. Examination - 1. WALK ALONG THE STRAIGHT LINE ~ normal person can walk. In vestibular nerve defect subject sways. 2. ROMBERG SIGN - subject is asked to stand with out-stretched hand, feet closed with eyes open and then eyes closed. * iF subject sways in both situation more with eyes closed -- vestibular defect at swaying side. * If swaying only in eye closed situation -- sensory ataxia, BARANY CALORIC TEST ~ irrigation each ear with hot (44°c) & cold (30%) water for 40 sec. and see for nystagmus. Observation - ‘Nystagmus appear with irrigation of ~ Condition of labyrinth 'S mi water Healthy labyrinth '5— 10 ml water Hypoactive labyrinth 10-40 ml water Dead labyrinth Cold water produce nystagmus > opposite sideHot water produce nystagmus > same side. (mimonic ~COWS). 4. BARANY CHAIR TEST ~ special type of chair, can be rotated at definite speed (20 times/ 10 sec.).Head of subject is tiited to specific position Observation — nystagmus at opposite eye is normal. In diseased labyrinth itis not present. Tinnitus — sensation of noises usually ringing in ear. Cause -- abnormal excitation of auditory apparatus or cortical area Hyperacusis ~ heightened sensitivity to sounds cause — hysteria, facial nerve palsy (stapedius paralysis). Reporting of the student — 1. Watch test and voice test are within normal limits. No lateralization in weber test Rinne positive in both ear. Subject can walk following a straight line without swaying, Romberg sign is negative. vestibulocochlear nerve of both sides of subject is normal. GLOSSOPHARYNGEAL NERVE (IX) =nixea parts Cells of origin supply Function Sensory Superior & inferior | 1.Posterior 1/3" of tongue. ‘Taste and general ganglia of 9 nerve sensation of tongue 2. Tonsils soft palate, part of the | 2.General sensory pharynx. sensation 3. Baro & chemo receptors in carotid sinus & carotid bodies. 3.Blood pressure regulation Motor Nucleus ambiguous _ | Stylopharyngeus Swallowing Parasympathetic | Inferior salivary | Parotid gland secretomotor nucleus History — difficulties in taste (bitter) sensation. History of postural syncope. Examination — 1. Inspection — see the soft palate with the help of torch and see any deviation of uvula. 2. TASTE SENSATION ~ in posterior 1/3" (as in facial nerve), 3. PHARYNGEAL OR GAG REFLEX ~ open mouth widely and trickle the back of pharynx with swab stick. Observation ~ contraction of posterior pharyngeal wall 4, PALATAL REFLEX (afferent 5" and 9* & efferent by 10" cranial nerve). -open mouth, touch mucous membrane of soft palate with cotton swab. Observation — soft palate normally elevate ‘ahh’ test — ash patient to say ‘ahh’ > soft palate raise symmetrically on both side. 5. BP RESPOND ON STANDING (TEST FOR ORTHOSTATIC HYPOTENTION) ~ measure BP in supine, then ask subject to stand up and BP measured within 15 seconds. Observation — if BP decreases > 20 mmHg, there may be defect in the 9* cranial nerve.Palatal reflex (Ahh test) VAGUS NERVE (X) = mixed nerve TYPE CELLS OF ORIGIN | SUPPLY FUNCTION Sensory Nodos ganglia then | 1.All structures supplied by vagus. visceral sense (pain, ending in NTS 2. aortic body, aortic arch. (bar & | stretch etc. chemo receptor) 2. BP regulation Motor Nucleus ambiguus | Muscles of pharynx and larynx Swallowing, respiration, phonation. parasympathetic | Dorsal nucleus of | 1 Heart ‘Leardiac inhibitory vagus, nucleus | 2.smooth muscles of bronchi, | 2. secretomotor ambiguus esophagus, stomach and small intestine (upto proximal 2/3 of transverse colon) History — difficulties in swallowing, phonation, hoarseness of voice, history of syncope. Examination — 1. Palatal reflex (‘Aah’ test) 2. Pharyngeal reflex 3. Laryngeal reflex tested by laryngoscopy. ACCESSORY NERVE (XI) tt has two parts: 1. Cranial part ~ supplies all muscles of soft palate, pharynx and larynx. 2. Spinal part - supplied trapezius, sternomastoid. History — weakness of turning head and rai Examination - ising shoulder. Inspection ~- trapezius from behind, dropping of shoulder, |ook for sternomastoid atrophy. Test- {Examination of trapezius ~ ~- ask the subject to shrug the shoulder without res ~ in palsy dropping of shoulder occurs. 2.Examination of sternomastoid €) Ask the subject to move chin one side against resistance (do bilaterally) fance and against resistance. b) Ask the subject to depress chin against resistance (both side examined in same time). ~- Both UMN and LMN supply ipsilateral sternomastoid (contrast to other muscle).‘TEST FOR TRAPIZIUS MUSCLE "TEST FOR STERNOMASTOID_ HYPOGLOSSAL NERVE (XII ‘Supply tongue muscle and depressor of hyoid bone. History — difficulties in speaking, chewing, swallowing. Examination - Inspection - deviation, atrophy, fasciculation of tongue. Test ~ 1. Ask the subject to move tongue side by side and protrude tongue. 2. Bulge out his check with tongue against external resistance. urely motor. ~ In UMN palsy ~> tongue is deviated to opposite side. In LMIN palsy -> tongue is deviated to same side. HYPOGLOSSAL MUSCLE TESTHEMATOLOGY Definition the branch of science that deals with the study of blood. (Greek Haema = Blood; logos = study). The Compound microscope (vz Discovered by ~ Antony Von Leeuwenhock Compound microscope is called so because, in contrast to a single magnifying convex lens, it has two such lenses ~ the objective and the eye piece. Principle — a focused beam of light scans the object. Parts of the specimen (that are optically dense, higher refractive index and colored with stain) cast a potential image like shadow, which is magnified in different stages as it passes up to the eye, coarse Body Tebe fajastacnt Fine Ovjectives hajeotacnt fa Joint Wisror(Lieht Source) © ase Sondensor fajustacnt PARTS OF MICROSCOPE Parts — A. The support system B. The focusing system C._The optical (magnifying) system D. The illumination system Ne> THE SUPPORT SYSTEM Base —a heavy metallic horseshoe-shaped base support whole apparatus and provides stability. Pillars - two upright pillars project up from base and attached with C- shaped handle with hinge to move at suitable angle for comfortable viewing. (microscope never tilted during counting cells in a chamber or when examining a blood film under oil immersion) Handle —C- shaped, supporting the focusing and magnifying systems. Body — it consists of two tubes with telescopic arrangement. a) Outer tube (body tube) - revolving nosepiece and objectives are attached. b) Inner tube (draw tube) ~ contains eyepiece with two lenses at two ends. it contains ~5. The stage - two components ~ a) Fixed stage a square platform with a central aperture (to pass light) fitted below the objective lens to place slides on it b) Mechanical stage ~ a calibrated (with Vernier scale to measure movement) metal frame fitted on the right edge of the fixed stage. A spring mounted clip to hold the slide or counting chamber in position while two screw-head moves it from side to side and forward and backward. 8, THE FOCUSING SYSTEM — consists of coarse and a fine adjustment screw for raising and lowering the optical system to focus the slide and place the objective lens at its focal length. One rotation of coarse adjustment moves tube 0.1 mm and fine adjustment 0.002 mm. v Left hand used for both adjustment screw and right hand used for handling mechanical stage, c. OPTICAL (MAGNIFYING) SYSTEM — consists of - a) Eye piece — itis fitted at the top of body tube one lens at the top (eye lens) and other at the bottom (field lens). Most microscopes are provided with 5x, 8X, 10X eyepieces. b)_ Nosepiece ~it carries interchangeable objective lens. Distance from nosepiece to eye piece is 16- em. ©) Objectives ~ 3 spring-loaded objectives of varying magnifying powers are usually provided. ‘Objectives Magnification | Numerical | Use Condenser | Diaphragm | Mirror with eyepiece | Aperture- NA Low 10 times 10 x10 = 100 [Less than | 1for Low Partially | Concave power (LP- times that of | initial | position —_| closed 10x) condenser | focusing 2wviewing large area of specimen slide High 45 times 45 X 10 =450 | Almost | For detail [ Mid ‘Almost | Plane power times, equal to] study of | position | open (HP=45X) condenser | material oll T0Otimes [100 Xi00 =| Greater | For Highest | Fullyopen | plane immersion | almost touch | 1000times | than to| detailed _| position (01-100x) | the slide condenser | study of {oil 7 NA) | material (cedar wood oil isused) Parfocal system - the objective lenses now are so constructed that when one lens (eg.LP) isin focus, the others are more or less in focus. This switching from one lens to another (LP > HP) requires only a little turn of fine adjustment to bring the image into a sharp focus. This arrangement of lenses is called ‘parfocal system’ D. ILLUMINATION SYSTEM —Auniform, soft and bright illumination is required for optimal illumination. Two factors are involved for this ~ a) position of condenser b) size of the iris diaphragm. Illumination system consists of ~ 1. Mirror — it consists a plane mirror in one side and 2 concave mirror in other side and can be changed by rotation, 2. Light source ~ light may be external day light source or internal source (by replacing mirror a frosted tungsten electric microscope lamp is used). 3. Condenser — Abbe type condenser is used mounted below the stage containing two lenses.it can be raised or lowered by a rack and pinion and focuses the light rays into a solid cone of light onto the ‘material under study and also helps in resolving the image. It is used in case of high power and oil immersion objective where diameter of lensis very small and naturally allow less amount of light. In low power objective lens has greater diameter which allows more light so condenser not used as it cause entry of excess light. 4, Iris diaphragm ~ its fitted within condenser and regulate the amount of light entry by using a shutter. It decreases numerical aperture of condenser, Functioning of microscope — Light from source > reflected from mirror > enter through diaphragm aperture > converted to a solid cone of light by condenser ~> strike object perpendicularly > rays from lighted object are collected by objective lens > a real magnified image is formed > converted by a magnified virtual image by lens system of eyepiece which person sees. Procedure of microscopy — Microscope is placed on the table and slide to be examined on stage > mirror concave, condenser down, diaphragm partially open & LP objective is lowered with coarse adjustment screw ~> look through the eye piece and objective is raised slowly until object is seen -> mirror is then adjusted and proper focusing is done with the help of fine adjust ment screw. Now change to HP objective > mirror plane, condenser midway, diaphragm almost open and only by fine adjustment focusing done. For Ol objective > mirror plane, condenser up, diaphragm fully open > one drop cedar wood cil placed over slide and focused by fine adjustment screw. Other types microscopes — 1. Binocular microscope 2. dark field microscope 3. fluorescence microscope 4. polarizing microscope 5. electron microscope Some relevant points —- 1. Cedar wood oil, liquid paraffin, glycerin (same refractive index as of glass) is used in oil immersion objective. te a.‘ numerical aperture thus resolving power of objective b. J Diffraction power of light rays by air which is present between material and lens in LP & HP. c. The speed of travelling of light rays. 2. Resolving Power ~ it is the ability to show closely located structures as separate and distinct from each other. Human eyes can separate dots as little as 0.25 mm apart where as light microscope can separate points 0.25 wapart. 3. Limit of resolution (LR) - the minimum distance between two points which can be seen as separate is termed as LR. LR = (0.61 X wave length of light) / numerical aperture.4, Numerical Aperture (NA}- NA of a lens, which is an index of its power of resolution, is the ratio of its diameter to its focal length. As the NA increase resolving power of the lens increases. 5. Working Distance it is the distance between lowest part of the objective and the slide examined. It is about 8-13 mm in case of low power objective and 1-3 mm in high power objective and 0.5- 1.5mm in oil immersion objective. PREPARATION OF A BLOOD FILM eva: Ithas 3 steps ~ A. Collection of blood sample. B. Drawing of blood film Fixing & Staining of blood film D. > Collection of blood sample - COLLECTION OF BLOOD. a) Apparatus and materials — disposable sterile blood lancet / pricking needle, sterile cotton, 70% rectified spirit, 3-4 grease free glass slides b) Procedure - Asepsis of finger pulp done by sterile sprit cotton > fresh pricking is done at the pulp by sterile disposable needle > allow a medium sized drop of blood to form on fingertip ~> previously cleaned grease-free glass slide is touched 11cm interior from the narrow edge (if anticoagulated blood is being used, place a drop of blood in similar position with a dropper). B. Drawing of blood film - Place the slides on the table containing a white paper on it (blood drop at the right side) > support the left end of the slide with thumb and fingers of left hand now grasp the long edges of a second slide (spreader slide) between thumb and fingers of right hand > the smooth edge of the spreader slide is placed in front of blood drop at 45° angle > spreader slide then drawn backward to touch the blood drop > blood now spread along the edge of spreader slide -> now spreader slide is moved forward at optimum and uniform speed without any interruption. Features of an ideal blood film - A) Naked eye appearance - 1. Light pink in color. 2. Tongue shaped. 3. Occupy the middle 2/3 of slide with a clear margin of about 2mm on either side. 4, Translucent, uniformly thick, neither very thick nor very thin 5. There should be no striation. 6. It should not have vacuole. B) Under microscope - 1. Most part of film should be one cell thick, ‘no overlapping of cells. 2. No gap in film 3. There should be no rouleaux formation. Parts of a blood film — 3 parts DRAWING OF BLOOD FILM1) Head~starting portion. 2) Body - main portion. 3) Tail - tip portion. Few relevant points — 1. More the angle of spreader approaches the vertical, the thinner the film and lesser angle, thicker the film, yawn result in — Thin film cause pushing of large cells (neutrophil, monocyte) to the periphery cause erroneous result. Thick film cause overlapping of cells causes difficult to identify cells. Thick film is required to detect Malarial parasites. The blood film should be drawn promptly after placing the drop of blood on the slide as delay may a. Uneven distribution of WBC in the smear. b. Rouleaux formation of RBC. ¢. The blood may clot. 6. Film should be dried immediately by waving to prevent rouleaux formation and distortion of RBC (gradual evaporation of water from plasma cause crenation of RBC) 7. Handkerchief not used for cleaning slide as it causes greasing of slide. 8. Inchildren blood taken from heel. C. Fixing & Staining of blood film - iB - it is the process by which the blood cells are made to adhere to the slide and done by methyl alcohol. Staining - it s the process by which cells (cytoplasm and nucleus) are stained Requirement — 1. Leishman stain — this is a mixture of methylene blue and eosin in acetone & water free methyl alcohol. Methylene blue (basic dye -positively charged) Stain the negatively charged acidic part of the cell (nuclei, granules of cytoplasm especially of basophil) Eosin (acidic dye — Stain the positively charged basic part of cell (eosinophil granule, hemoglobin negatively charged) of RBC). ‘Acetone and water free | Alcohol is 1. Fixative, precipitates the plasma protein which then acts as a methyl alcohol glue and fix the cells. 2. Preserves the morphology and chemical status of cell ‘* Alcohol is acetone free because acetone is very strong lipid solvent and cause crenation, shrinkage or even destruction of cell membrane. ‘© Alcohol is free from water as water cause rouleaux formation and even hemolysis. Other stain - Write stain, Giemsa stain. 2. Staining tray — it consists of two glass rods placed parallel about $ cm apart. 3. distilled water. 4, Pasteur pipette. 5. Blood smeared slides. Procedure — i, 2-8 blood films are made, dried and placed on glass rods of staining tray. ii, About 8 -10 drops of Leishman stain is poured to cover the whole film. iii, Wait for 1 -2 minutes (fixation time) and look for not drying of stain,iv. Double amount of distilled water is now poured by Pasteur pipette and wait for 7 -10 minutes (staining time — water causes ionization of stain and stain now enter the cell) and blow gently for mixing dye and look for a greenish scum at the top of the mixture. v. Now pour off stain and wash the slide gently and thoroughly under tap water (water not fall directly on smear). vi, Drythe film. EXAMINATION OF A STAINED BLOOD SMEAR~prv2.11) Features of well stained smear — 1. Naked eye appearance ~ smear appear translucent, bluish pink, uniformly thick throughout. 2. Under low power — RBC appears as dots, uniformly spread-out in a single layer. W8Cs cannot be differentiated. 3. Under high power ~ RBCs are stained dull orange-pink and show central pallor. ‘WBCS scatteredly distributed within WBCs. Nuclei deep blue-violet. Plates occur in small groups. Staining defects — 1. Presence of stain granules — round solid-looking deep blue-violet particles of stain scattered. Causes — old stain / stain not filtered / dry up of film during fixing / insufficient washing. 2. Excessive blue appearance of cells — Causes - over staining / over fixing / insufficient washing /use of alkaline stain and water. 3. Excessive reddish appearance of cells — Causes - under staining / over washing / use of more acidic stain and water. Identification of cells under oil immersion — a. RBC-- orange-pink, numerous, evenly spread out, non-nucleated, 7.2 ~ 7.8 im size, central paleness occupying central third of the cell but is wider in anemia. There may be some overlapping, overcrowding or even rouleaux formation at head end. b. WBC ~ 3 types of granulocytes (neutrophil, eosinophil, basophil) and 2 types of agranulocytes (monocyte, lymphocyte) are seen. Size compared with that of RBC. Celltype | diameter | nucleus cytoplasm histology Granulocyte Neutrophils | 10-15 + Blue-violet * Pale-pink (40-70%) | um (1.5— Fine pink granules