Normal Pulse and Its Variants

The normal pulse has a small anacrotic wave on the upstroke which is not felt. This is followed by a big tidal or percussion wave which is felt by the palpating finger. On the following downstroke there is a notch (dicrotic notch) followed by a wave (dicrotic wave) both of which are not normally palpable.

The normal pulse appears at regular intervals and has a rate between 60-100 per min. There may be a mild variation in the rate between the two phases of respiration which is called sinus arrhythmia. Read more

Causes of Hypothermia

Hypothermia

Hypothermia is decreased body temperature.

Causes

1. Endocrine: Myxedema, Simmond’s cachexia, hypoglycemia
2. Toxic: Alcoholic intoxication, barbiturate poisoning, ketoacidosis
3. Exposure to cold
4. Autonomic dysfunction

Fever - Definition, Types, Causes and Effects

The body temperature refers to the temperature of the viscera and tissues of the body. It is kept within the normal level by maintaining a balance between the heat gain and heat loss, which is regulated by the hypothalamus.

The body temperature is best recorded with a mercury thermometer which should be kept in position for about a minute. Usually temperature is recorded in the axilla. However, if there is a lot of perspiration, oral temperature should be taken. In cholera, rectal temperature is recorded which may be high, whereas the skin temperature may be subnormal.

The normal body temperature varies from 36 degree Celsius - 37.5 degree Celsius. There is normally a diurnal variation of 1 degree Celsius, the lowest temperature being between 2-4 am and highest in the afternoon.

Fever or pyrexia is an increase of more than 1 degree Celsius or any rise above the maximal normal temperature.

Types of Fever

1. Continuous fever: The temperature remains above normal throughout the day and does not fluctuate more than 1 degree Celsius in 24 hours e.g. lobar pneumonia, typhoid, urinary tract infection, infective endocarditis, brucellosis, typhus, etc.
2. Remittent fever: The temperature remains above normal throughout the day and fluctuates more than 2 degree Celsius in 24 hours e.g. typhoid, infective endocarditis, etc. This type of fever is most common in practice.
3. Intermittent fever: The temperature is present only for some hours in a day and remains to normal for the remaining hours. When the spike occurs daily, it is quotidian, when every alternate day, it tertian and when every third day, it is quartan. Intermittent fever is seen in malaria, kala-azar, pyemia, septicemia etc.
4. Hectic or septic: The temperature variation between peak and nadir is very large and exceeds 5 degree Celsius e.g. septicemia.
5. Pel Ebstein type: There is a regular alternation of recurrent bouts of fever and afebrile periods. The temperature may take 3 days to rise, remains high for 3 days and remits in 3 days, followed by apyrexia for 9 days.
6. Low grade fever: Temperature is present daily especially in the evening for several days but does not exceed 37.8 degree Celsius at any time. Usually it does not indicate disease, but it is commonly present with tuberculosis.

Causes of Fever

1. Infection: Bacterial, viral, rickettsial, fungal parasitic, etc.
2. Neoplasms: Fever may be present with any neoplasm but commonly with hypernephroma. Lymphoproliferative malignancies, carcinoma of pancreas, lung and bone and hepatoma.
3. Vascular: Acute myocardial infarction, pulmonary embolism. Pontine hemorrhage, etc.
4. Traumatic: Crush injury
5. Immunological:

• Collagen disease, SLE, rheumatoid arthritis.
• Drug fever
• Serum sickness

6. Endocrine: Thyrotoxicosis, Addison’s disease.

7. Metabolic: Gout, porphyria, acidosis, dehydration

8. Hematological: Acute hemolytic crisis

9. Physical agents: Heat stroke, radiation sickness.

10. Miscellaneous: Factitious fever, habitual hyperpyrexia, cyclic neutropenia

Special Types of Fever

1. Fever with rigors: This occurs in:

• Malaria
• Kala azar
• Filariasis
• Urinary tract infection
• Cholangitis
• Septicemia
• Infective endocarditis

2. Fever with herpes labialis: Elevated body temperature may activate the herpes simplex virus and cause small vesicles around the angle of the mouth (herpes labialis). It occurs with:

• Pneumonia
• Malaria
• Meningitis
• Streptococcal infection

3. Fever with rash: This is seen in:

• Chicken pox
• Small pox
• Measles
• Rubella
• Typhus
• Allergy

4. Fever with membrane in the throat: occurs in:

• Diphtheria
• Infectious mononucleosis
• Agranulocytosis
• Moniliasis
• Vincent’s angima

5. Fever with delirium: This is common in:

• Encephalitis
• Typhoid state
• Meningitis
• Pneumonia (especially in alcoholics and elderly people with senility)

6 Hyperpyrexia
Hyperpyrexia is said to occur when body temperature is more than 105 degree Fahrenheit.

1. Tetanus
2. Malaria
3. Septicemia
4. Heat Stroke
5. Encephalitis
6. Pontine hemorrhage

Benefits of Fever

In some human disease, fever is beneficial, e.g. widespread cancer, neurosyphilis, chronic arthritis, etc. Fever was often induced in these diseases by injection of milk protein or BCG vaccine.

It has been suggested that fever is associated with release of endogenous pyrogens, which activate the T cells and thus enhance the host defense mechanism.

Harmful Effects

1. Hypercatabolism-nitrogen wastage and weight loss.
2. Fluid and electrolyte imbalance-due to sweating.
3. Convulsions and brain damage
4. Circulatory overload, arrhythmia, etc.

What is Pes Cavus and What Causes It

Pes Cavus: Pes cavus is the increased antero-posterior curvature of the arch of the foot.

Causes:

1. Idiopathic
2. Spinocerebellar atrophy: Friedreich’s ataxia, peroneal muscular atrophy
3. Spinal cord disease: Poliomyelitis, spina bifida
4. Cerebral palsy

Deformities of The Vertebral Column With Causes

The vertebral column in a normal upright position has two antero-posterior curves-one with a concavity forwards in the upper dorsal region and the other with a slight convexity forwards in the dorsolumbar region. Normally, there is no lateral curvature. The vertebral column should be examined for any abnormality, angular deformity, swelling or tenderness.

Normally the vertebral column has both anterior as well as lateral mobility. This can be tested by asking the patient to bend forwards, backwards and sideways. Limitation of movements and pain, if any, should be looked for.

I. Scoliosis: Scoliosis is an abnormal lateral curvature of the spine.

Causes:

1. Congenital
2. Postural: Carrying heavy weight in one arm.
3. Compensatory: Reduced length of one lower limb.
4. Reflex: To relieve pain as in sciatica or renal colic.
5. Neurological: Poliomyelitis, syringomyelia, muscular dystrophy, hereditary ataxia.
6. Rickets
7. Functional

II. Kyphosis: Kyphosis is an abnormal anterio-posterior curvature of the spine with forward concavity and dorsal prominence.

Causes:

1. Congenital: Wedge shaped vertebra
2. Postural: Carrying weights on the back
3. Disease of bone and joints: Tuberculosis (Pott’s spine), rheumatoid arthritis, rickets, osteoarthritis, osteitis deformans, fracture of the vertebral body, new growth of the spine.
4. Neurological: Muscular dystrophy, hereditary spastic paraplegia, Friedreich’s ataxia, sryingomyelia, poliomyelitis, cerebral palsy, neurofibroma, etc.

III. Lordosis: Lordosis is an abnormal anterior-posterior curvature of the spine with forward convexity.

Causes:

1. Physiological: Pregnancy
2. Secondary to hip disease and congenital
3. Muscular dystrophy
4. Large abdominal tumors

List of Causes of Thickened Nerves

• Leprosy
• Neurofibroma
• Diabetes
• Amyloidosis
• Charcot Marie Tooth syndrome
• Sarcoidosis
• Refsum’s disease
• Rusy Levy syndrome
• Dejerine Sotta’s syndrome
• Idiopathic hypertrophic neuropathy

List of Causes of Arthritis

Causes of Arthritis

Acute arthritis

• Traumatic
• Infection: Gonorrhea, septic, typhoid, bacillary dysentery, rheumatic, Reiter’s syndrome, etc.
• Gout
• Scurvy
• Hemophilia
• Acute attacks in chronic arthritis

Chronic Arthritis

1. Infection: Tuberculosis, syphilis, rheumatic
2. Collagen disease: Rheumatoid, SLE, Polyarteritis nodosa
3. Degenerative: Ankylosing spondylitis
4. Neuropathic: Tabes dorsalis, syringomyelia
5. Miscellaneous: Hemophilia, gout.

Examination of Nails For Systemic Diseses

The nails should be examined for the following:

• Pallor
• Koilonychia: Spoon-shaped deformity of the nail which is present in iron deficiency anemia.
• Onychia: Deformity of the nail e.g. following fungal or tuberculous infection.
• Discoloration: This occurs in Raynaud’s disease and silver and mercury poisoning.
• Clubbing and cyanosis: Clubbing is bulbous enlargement of soft parts of the terminal phalanges with both transverse and longitudinal curving of the nails. The swelling of the terminal phalanges in clubbing occurs due to interstitial edema and dilation of the arterioles and capillaries. Cyanosis is a bluish discoloration of the nails due to increased amount of reduced hemoglobin (more than 5 mg%)in capillary blood.
• Hemorrhages: This may be present under the nail beds in SBE and bleeding disorders.
• Trophic changes: Ribbing, brittleness and often falling of nails may occur in syringomyelia, leprosy and tabes dorsalis.

Examination of Skin For manifestation of Systemic Disease

Examination of skin often gives important clues to local or systemic diseases. The following features should be noted:

Color: It may be pale, flushed, cyanosed, yellow, etc.

Pigmentation: Pigmentation may occur in several diseases. Some common medical conditions associates with pigmentation are:

• Endocrine: Addison’s disease, Cushing’s disease, thyrotoxicosis.
• Deficiency: Pellagra, Kwashiorkor.
• Infections: Kala azar, chronic malaria, secondary syphilis, tuberculosis, leprosy, etc.
• Metabolic: Hemochromatosis.
• Skin disease: Neurofibromatosis, lichen planus, acanthosis nigricans, etc.
• Miscellaneous: Malignancy, pernicious anemia, exposure to sun rays or radiations.

Hypopigmentation: Hypopigmented patches may occur in leprosy, leukoderma, albinism, fungal infections of skin, etc.

Eruptions: Various types of eruptions may occur as follows:

• Macules: (Not raised above the skin). This may occur in typhoid, syphilis and purpura. If they are not generalized they are called roseollar.
• Papules: (Raised tiny nodules): This may occur in measles, chicken-pox, smallpox, and following drugs like sulfonamides.
• Pustules: These are papules containing pus.
• Nodules: (Large papules solitary projection from the skin). This may occur in erythema nodosum, leprosy, tuberculosis, secondary syphilis.
• Vesicles: (Small blisters). This may occur in herpes, chicken-pox and smallpox..
• Wheat: (Elevated patches on the skin with center paler than the periphery), Allergy.
• Café-Au-Lait patches: Dark brown patches resembling coffee in milk. They are considered significant if they are more than 5 in number. They are seen in:
  • Neurofibromatosis (regular outline without deep indentations).
  • Albright’s syndrome (irregular outline with deep indentations).

Hemorrhagic: Hemorrhage under the skin is classified as follows:

• Petechiae: Tiny hemorrhage less than 1 mm in diameter.
• Purpura: Hemorrhage 2-5 mm in diameter.
• Ecchymosis: Hemorrhage more than 5 cm in diameter.
• Hematoma: Hemorrhage large enough to produce elevation of skin.

Causes of hemorrhage under the skin:

• Deficiency: Vitamin deficiency, scurvy.
• Infection: Meningococcal meningitis, SBE, HIV.
• Hematological: Thrombocytopenia, acute leukemia, chronic lymphatic leukemia, chronic myeloid leukemia (in terminal phase) platelet dysfunction and aplastic anemia.

Type of Skin

• Dry skin: This is seen in myxedema and dehydration.
• Moist skin: This occurs when there is profuse perspiration as in shock, following myocardial infarction, crisis of pneumonia and thyrotoxicosis.
• Thick skin: This occurs in Myxedema, acromegaly and scleroderma.
• Thin skin: This occurs in old people and following wasting diseases.
• Pinched skin: suggests dehydration.

Hair: Changes in hair that occurs in some of the diseases are as follows:

• Falling of hair: Following infectious fevers e.g. typhoid.
• Patchy hair loss: Alopecia areata, syphilis.
• Loss of outer third of the eyebrows: Leprosy, Myxedema.
• Absence of axillary, pubic and facial hair: Hypopituitarism, hypogonadism.
• Excessive hair growth in women: Cushing’s syndrome, adrenocortical syndrome.

Making A Diagnosis In Patient of Edema

Congestive Cardiac Failure

• The edema is found on the most dependent parts of the body as gravity plays an important part.
• In an ambulatory patient edema is in the feet, ankles and legs
• In the recumbent patient it is mainly over the sacrum, lumbar region and genitalia.
• Edema is most marked in the evening.

Left ventricular failure

Here accumulation of fluid in the lung comes much earlier than edema of the feet, resulting in

• Dyspnea
• Cough
• Basal rales.

Pericardial effusion

Here since there is obstruction to the flow of blood into the right atrium, edema of feet may occur, but no edema of lungs occurs because the heart is able to pump the little blood it receives into the lungs and general circulation. It is associated with raised JVP, hepatomegaly and ascites.

Acute nephritis

• Edema is generalized and not restricted to the dependent parts of the body.
• It is more noticeable in the early morning.
• The fluid accumulates initially in the loose connective tissues, hence it is most marked around the eyelids and face.
• The cause of edema is damage to the endothelial lining of the capillaries, disturbance of fluid and sodium excretion and later also due to hypoproteinemia.

Nephrosis

The swelling is generalized and massive due to hypoproteinemia following massive albuminuria.

Hepatic (Portal hypertension):

Here ascites occurs before edema of feet. This occurs due to hypoproteinemia and compression of the hepatic branches of the portal vein. Ascites leads to pressure on the venous circulation in the lower limbs leading to edema of the legs.

Inferior vena cava obstruction

This is characterized by bilateral nondependent painless pitting edema. Collateral dilated veins are usually present in the flanks with flow of blood from below upwards.

Myxedema

Here edema is non-pitting, associated with puffy face, weight gain, weakness, alopecia, hoarse voice, rough dry skin, constipation, anemia and menstrual disturbances.

6. Allergic (Angioneurotic edema):

This often resembles myxedema with swelling over the face and limbs. There is usually intense itching and bronchospasm.

7. Nutritional:

This is characterized by dependent edema with puffiness of face, pallor and cachexia.

8. Filariasis:

In filariasis, edema occurs due to destruction of the lymphatic filter action of the lymph glands with consequent blocking and dilation of the lymph vessels. Subsequently there is transudation of lymph, rich in proteins, into the tissues. Later connective tissues proliferate leading to elephantiasis. This is characterized by unilateral non-pitting edema with rough skin. There may be history of fever with rigors especially at night and initially pitting edema. Blood smear may show microfilaria.

9. Gout:

This commonly affects the big toe with marked pain, edema and deformity of the part involved. Tophi may be present. There may be history of renal colic or renal stones.

10. Venous Thrombosis:

This is characterized by unilateral painful pitting edema.

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