Human Anatomy and Physiology Practical Workbook [First Edition] 9789354665523

Table of contents :
Front Cover
Half Titel Page
Title Page
Copyright
Preface
Syllabus
Contents
Semester I
1. Compound Microscope
2. Microscopic Study of Epithelial and Connective Tissues
3. Microscopic Study of Muscular and Nervous Tissues
4. Identification of Axial Bones
5. Identification of Appendicular Bones
6. Introduction to Hemocytometry
7. Enumeration of White Blood Cell Count
8. Enumeration of Total RBC Count
9. Determination of Bleeding Time
10. Determination of Clotting Time
11. Estimation of Haemoglobin Concentration
12. Determination of Blood Group
13. Determination of ESR
14. Determination of Heart Rate and Pulse Rate
15. Recording of Blood Pressure
Semester II
1. Integumentary and Special Senses
2. Nervous System
3. Endocrine System
4. Demonstration of General Neurological Examination and Cranial Nerves
5. Demonstration of the Function of Olfactory Nerve
6. Examination of the Different Types of Taste
7. Demonstration of the Visual Acuity
8. Demonstration of Reflex Activity
9. Recording of Body Temperature
10. Demonstration of Positive and Negative Feedback Mechanism Experiments
11. Determination of Tidal Volume and Vital Capacity
12. Systems of the Body
13. Recording of Body Mass Index
14. Study of Family Planning Devices and Pregnancy Diagnosis Test
15. Demonstration of Total Blood Count by Cell Analyzer
16. Permanent Slides of Vital Organs and Gonads
Back Cover

Citation preview

Human

Anatomy and Physiology Practical Workbook Course Codes: BP107P and BP207P

for First and Second Semesters Bachelor in Pharmacy As per the latest syllabus prescribed by Pharmacy Council of India

Related Publications

Other Titles Authored/Edited by Dr Krishna Garg 1. BD Chaurasia’s Human Anatomy, 9th Edition [Volumes 1–4] 2. BD Chaurasia’s Handbook of General Anatomy, 6th Edition 3. BD Chaurasia’s Human Anatomy for Dental Students, 4th Edition 4. Manual of Human Anatomy Dissection 5. Practical Anatomy Workbook, 3rd Edition 6. Human Anatomy and Physiology : Theory and Practical for Diploma in Pharmacy Students, 2nd Edition 7. Practical Histology Workbook, 2nd Edition 8. BD Chaurasia’s Human Embryology, 2nd Edition 9. Textbook of Histology, 5th Edition 10. Textbook of Neuroanatomy with Cinical Orientation, 6th Edition 11. Anatomy and Physiology for Nursing and Allied Health Sciences 12. Anatomy and Physiology for GNM Students 13. Anatomy and Physiology for BSc Nursing Students 14. Anatomy and Physiology for Nursing (Hindi) 15. Anatomy and Physiology for Allied Health Sciences (Hindi) 16. Companion Pocketbook BD Chaurasia’s Human Anatomy [Volumes 1–3]

Human

Anatomy and Physiology Practical Workbook Course Codes: BP107P and BP207P

for First and Second Semesters Bachelor in Pharmacy As per the latest syllabus prescribed by Pharmacy Council of India

Krishna Garg

MBBS MS PhD FAMS FASI, Legend of Anatomy

Ex-Professor and Head Department of Anatomy Lady Hardinge Medical College, New Delhi

Medha Joshi

Sudipta Kundu

Guest Faculty Pt Deendayal Upadhyaya National Institute for Persons with Physical Disabilities, New Delhi, and Amar Jyoti Institute of Physiotherapy, Delhi

Associate Professor and Head Department of Physiology Kalka Dental College Meerut, UP

MBBS FCGP

MSc PhD

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Disclaimer Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies. eISBN: 978-93-546-6552-3 Copyright © Authors and Publisher First eBook Edition: 2023 All rights reserved. No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher. Published by Satish Kumar Jain and produced by Varun Jain for CBS Publishers & Distributors Pvt. Ltd. Corporate Office: 204 FIE, Industrial Area, Patparganj, New Delhi-110092 Ph: +91-11-49344934; Fax: +91-11-49344935; Website: www.cbspd.com; www.eduport-global.com; E-mail: [email protected]; [email protected] Head Office: CBS PLAZA, 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi-110002, India. Ph: +91-11-23289259, 23266861, 23266867; Fax: 011-23243014; Website: www.cbspd.com; E-mail: [email protected]; [email protected].

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Representatives Hyderabad Pune Nagpur Manipal Vijayawada Patna

Preface I hear, I imagine; I see, I remember; I do, I understand

T

he above quotation rightly applies to this book, i.e. one only understands fully after manually doing any job. A practical workbook is essential for learning the various facets of pharmacy theory. It also teaches one to understand the mechanisms occurring in any organ system of the human body. This Practical Workbook guides the students to complete physiology practicals manually with the help of various pieces of laboratory equipment. For the practical part of anatomy, many diagrams are given in detail as per the syllabus requirements. These illustrations have to be understood with the help of the theoretical information provided in the source books: Human Anatomy and Physiology I: Theory for First Semester Bachelor in Pharmacy (ISBN  9789354661976) Human Anatomy and Physiology II: Theory for Second Semester Bachelor in Pharmacy (ISBN  9789354661228) Written by us and published under the same banner CBS Publishers & Distributors. After that various parts have to be labelled in the diagrams to get a full grasp of the topics concerned. As we are aware of ‘theoretical learning’ and ‘practical performance’ are the two sides of a coin. While studying human anatomy and physiology, theory and practical go hand in hand and complement each other thoroughly. This great combination helps us to learn, recapitulate for the various examinations during the study period and later on during the professional career. To do the practicals sensibly, the above mentioned books have to be studied thoroughly and referred to repeatedly to get in-depth knowledge of the topics and to clear any doubt in the mind. First part of the book is related to Semester I (Course Code BP107P) and the second part to Semester II (Course Code BP207P) human anatomy and physiology for Bachelor in Pharmacy students. The results of the practicals have to be recorded at the end of each chapter and in the lines under the heading of ‘observation exercise’. A few additional blank pages have been given for extra recordings. The laboratories in the institutions teaching bachelor in pharmacy courses are expected to have • articulated skeletons, • loose set of bones, • histological stained slides of various tissues, • charts and • models of all systems, and • proper equipment for manually performing the physiology practicals in small groups under expert guidance. This will ensure ideal learning for the students and will go a long way in the betterment of their careers.

Acknowledgements

W

e are are grateful to the Almighty for His guidance during the preparation of the text and illustrations of the Practical Workbook of Human Anatomy and Physiology for Bachelor in Pharmacy.

We extend our special thanks to Mr Satish Kumar Jain Chairman and Managing Director and Mr Varun Jain Director, CBS Publishers & Distributors Pvt Ltd, for their wholehearted support in publishing this book. The unquestionable support of Mr YN Arjuna Senior Vice President: Publishing, Editorial and Publicity, and his entire team comprising Ms Ritu Chawla GM—Production, Mr Manish Raj Graphic Artist, Ms Jyoti Sharma DTP Operator, Mr Neeraj Sharma Copyeditor and Mr Neeraj Prasad Graphic Artist is really appreciable. They have all done an excellent work to bring out the first edition of the book with appreciable quality. We are really obliged to all of them and pray for their prosperity.

Krishna Garg Medha Joshi Sudipta Kundu

Syllabus Human Anatomy and Physiology (Practical) Course Code BP107T

(4 Hours/week)

Practical physiology is complimentary to the theoretical discussions in physiology. Practicals allow the verification of physiological processes discussed in theory classes through experiments on living tissue, intact animals or normal human beings. This is helpful for developing an insight on the subject. 1. Study of compound microscope. 2. Microscopic study of epithelial and connective tissue 3. Microscopic study of muscular and nervous tissue 4. Identification of axial bones 5. Identification of appendicular bones 6. Introduction to hemocytometry. 7. Enumeration of white blood cell (WBC) count 8. Enumeration of total red blood corpuscles (RBC) count 9. Determination of bleeding time 10. Determination of clotting time 11. Estimation of hemoglobin content 12. Determination of blood group. 13. Determination of erythrocyte sedimentation rate (ESR). 14. Determination of heart rate and pulse rate. 15. Recording of blood pressure. Course Code BP207T

(4 Hours/week)

1. To study the integumentary and special senses using specimen, models, etc., 2. To study the nervous system using specimen, models, etc., 3. To study the endocrine system using specimen, models, etc 4. To demonstrate the general neurological examination 5. To demonstrate the function of olfactory nerve 6. To examine the different types of taste. 7. To demonstrate the visual acuity 8. To demonstrate the reflex activity 9. Recording of body temperature 10. To demonstrate positive and negative feedback mechanism. 11. Determination of tidal volume and vital capacity. 12. Study of digestive, respiratory, cardiovascular systems, urinary and reproductive systems with the help of models, charts and specimens. 13. Recording of basal mass index . 14. Study of family planning devices and pregnancy diagnosis test. 15. Demonstration of total blood count by cell analyser 16. Permanent slides of vital organs and gonads.

Certificate Student’s Name: Class:

Roll No.

Subject: This is to certify that experiments, written in the index, have been performed by the student, are satisfactory. Grade

College stamp



Name and signature of lab in-charge

Date

Certificate Student’s Name: Class:

Roll No.

Subject: This is to certify that experiments, written in the index, have been performed by the student, are satisfactory. Grade

College stamp



Name and signature of lab in-charge

Date

Contents Preface v Syllabus vi

Semester I 1. Compound Microscope 2. Microscopic Study of Epithelial and Connective Tissues 3. Microscopic Study of Muscular and Nervous Tissues 4. Identification of Axial Bones 5. Identification of Appendicular Bones 6. Introduction to Hemocytometry 7. Enumeration of White Blood Cell Count 8. Enumeration of Total RBC Count 9. Determination of Bleeding Time 10. Determination of Clotting Time 11. Estimation of Haemoglobin Concentration 12. Determination of Blood Group 13. Determination of ESR 14. Determination of Heart Rate and Pulse Rate 15. Recording of Blood Pressure

1 4 11 16 20 23 25 31 35 37 39 42 44 47 50

Semester II 1. Integumentary and Special Senses 2. Nervous System 3. Endocrine System 4. Demonstration of General Neurological E xamination and Cranial Nerves 5. Demonstration of the Function of Olfactory Nerve 6. Examination of the Different Types of Taste 7. Demonstration of the Visual Acuity 8. Demonstration of Reflex Activity 9. Recording of Body Temperature 10. Demonstration of Positive and Negative Feedback Mechanism Experiments 11. Determination of Tidal Volume and Vital Capacity 12. Systems of the Body 13. Recording of Body Mass Index 14. Study of Family Planning Devices and Pregnancy Diagnosis Test 15. Demonstration of Total Blood Count by Cell Analyzer 16. Permanent Slides of Vital Organs and Gonads

55 61 69 75 80 82 84 87 91 94 96 98 113 115 118 120

Semester I

1 Compound Microscope Study the different parts of a compound microscope and its uses.

A. Supporting Parts i. Base: It is a horseshoe or U-shaped struc­ture. It supports the microscope and provides stability. ii. Pillars: There are two pillars between the base and handle. It is an upright structure. It is attached to the handle by a hinge joint. iii. Handle: It is a curved, C-shaped structure and it helps in tilting the microscope. iv. Body tube: It is a wide tube attached to the C-shaped handle at the upper part. At the lower end it is attached to the nose­­piece. Eyepiece is placed at the upper end. v. Stage: Stage is comprised of two parts: a. Fixed stage: It is a fixed square stage and has a round aperture at the centre. Object is placed at the centre for study. The light rays coming from below cross this aperture and strike the object which is to be focussed. b. Mechanical stage: It is a calibrated stage (Vernier scale) and is fitted on the fixed stage. There is a clip attached to it which holds the object. There are two screws attached to it which control sideways, forward and backward (to and fro) movements of the object. Movement of the object can be determined by engraved Vernier scale on the mechanical stage.

COMPOUND MICROSCOPE The compound microscope is called so because it has two-lens system, i.e. the eyepiece and the objective lenses. Broadly, the parts of compound micro­s cope are divided into: a. Supporting parts (Fig. 1.1) b. Focusing parts c. Optical parts d. Illumination parts

B. Focusing Parts Coarse and fine adjustment screw: If one side screw is moved then the other side screw also moves along with it auto­matically. These screws work in “rack and pinion” method. Circular movement (pinion) of these screws helps in upward and downward movements (racking) of body tube. a. Coarse adjustment screw: There are two coarse adjustment screws mounted at the top of the handle on either side. The focussing of an object is always done by using coarse adjustment screw first. The body tube is moved in upward and

Fig. 1.1: Monocular compound microscope (front view)

1

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Human Anatomy and Physiology:  Practical Workbook

down­ward direction by the coarse adjust­ment screws. b. Fine adjustment screw: There are two fine adjustment screws mounted at the top of the handle on either side. These are small-sized screws and help in fine and sharp focussing after coarse focussing has been made with the coarse adjustment screws. C. Optical Parts Optical parts of microscope help in image formation (Fig. 1.2). i. Body tube: It is also considered as a part of optical system. ii. Eyepiece lens: It is placed at the uppermost part of the body tube. The eyepiece lens has different magnifying power, i.e. 5X, 10X, etc. which can be changed accord­ing to the requirement. It is comprised of two lenses: a. Eye lens: It is attached at the top most part of eyepiece lens. b. Field lens: It is present at the lower most part of eyepiece lens. iii. Nosepiece: It has two parts—fixed nose­piece and revolving nosepiece.

The fixed nosepiece is attached on the lower end of body tube. Revolving nosepiece is fitted below the fixed nosepiece. Different objective lenses are attached to the revolving nosepiece. iv. Objective lenses: There are four or three objective lenses with the different magni­fying powers attached to the revolving nosepiece. The magnifying power and the numerical aperture are engraved in each and every objective lens (Table 1.1). D. Illumination Parts i. Light: The source of light may be exter­nal or internal, i.e. light is attached with microscope itself (Fig. 1.3).   Sunlight or artificial light can be used as external source for microscope. ii. Planoconcave mirror: It is a double-sided mirror. One side is plane and the other side is concave in nature. That is why, it is known as planoconcave mirror. The plane mirror is used when sunlight is used as light source. Because sunlight rays are parallel in nature and reflected parallel

Fig. 1.2: Monocular compound microscope (front view) Table 1.1:  Magnification power, focal length and numerical aperture of objective lenses Objective lenses

Magnification power

Focal length

Numerical aperture (NA)

Scanning objective lens

3X

40 mm

0.10

Low power objective lens

10X

16 mm

0.25

High power objective lens

40X or 45X

4 mm

0.65

Oil immersion objective lens

100X

Less than 2 mm

1.30

Total magnification power = Magnification power of eyepiece lens × Magnification power of objective lens

Compound Microscope

to the condenser by plane mirror. The concave mirror is used in artificial light. Because artificial light rays are divergent in nature and reflected as parallel to the condenser by concave mirror. iii. Condenser: It is just below the cen­t ral aperture of fixed stage. It is a combi­nation of two lenses fitted in a short cylinder. The function of condenser is to converge light at the central aperture Fig. 1.3: Monocular compound of fixed stage. It also microscope (front view) reduces the spherical and chromatic aberrations. By the help of a screw, fitted at one side, condenser can be moved in upward and downward direction. This screw also work in rack and pinion fashion. While using scanning objective lens, the condenser should be at the lower­most posi­tion. During the use of low power objective lens, the condenser should be little bit upper from lower­ most position. Position of con­den­ser should be midway during the use of high power objective lens and at upper­most position while using oil immersion objective lens. iv. Iris diaphragm: It is present just below the condenser. It controls the amount of light. Its size of aperture can be changed by moving a small lever fitted on the side. It is opened least while using scanning objective lens. It is opened partially while using low power lens, almost open in high power and fully opened when oilimmersion objective lens is used. PROCEDURE: TO USE THE MICROSCOPE Using of Low Power Objective Lens • Place the microscope in working table towards the light source. • Select the mirror depending upon the source of the light. • Move the condenser little bit upper from the lowermost position. • Open iris diaphragm partially. • Bring the low power objective lens in align­ment by listening click sound (when low power objective lens is brought in the path of light then a click sound is heard on its rotation).

3

• Adjust light by looking through the eyepiece and by tilting the mirror towards light source. • Now, place the object at the centre on fixed stage. • Lower the body tube (low power objective lens also moves with body tube), gradually by coarse adjustment screw up to 3–4 cm away from the object. • Then look through eyepiece. • The field should be equally and fully illuminated. • Rotate coarse adjustment screw very slowly to move the body tube downward gradually until rough focus the object is done. • Use high power objective lens and fine adjustment screw to have an improved and clear focussing. • Bring the high power objective lens in alignment (in the path of light) by listening click sound. • Bring the condenser at midway position. • Open iris diaphragm almost fully. • Lower the body tube gradually by coarse adjustment screw as far as possible without touching the object while looking from the side. • Then look through eyepiece. • The field should be equally and fully illuminated by little bit adjusting mirror if required. • Now, elevate the objective lens, i.e. body tube slowly with the help of coarse adjustment screw until the object is visible. • Then use the fine adjustment screw to have an improved and clear focussing. Using of Oil Immersion Objective Lens • Elevate the body tube at least 2 inch from the object. • Bring the oil immersion objective lens in alignment (in the path of light) by listening click sound. • Put one drop of cedar wood oil over the object (the part of the object which is just above the centre aperture). Cedar wood oil has approximately same refractive index as that of glass and it replaces the thin layer of air which is present in between the object and oil immersion objective lens. Hence, it prevents the refraction of light and object will be more clearly visible. • Bring the condenser at highest position. • Open iris diaphragm fully. • Lower the body tube gradually by coarse adjustment screw until the tip of the oil immersion object touches the cedar wood oil drop while looking from the side. • Then look through eyepiece. • The field should be equally and fully illuminated by little bit adjusting the mirror if required. • Then, use the fine adjustment screw to have an enhanced and clear focusing.

2

Microscopic Study of Epithelial and Connective Tissues

Epithelial Tissue

Connective Tissue (Specialised)



a. Cartilage • Hyaline (Fig. 2.8) • Elastic (Fig. 2.9) • Fibrocartilage (Fig. 2.10) b. Bone • Compact (Fig. 2.11) • Cancellous (Fig. 2.12)

a. b. c. d. e. f. g.

Squamous (Fig. 2.1) Cuboidal (Fig. 2.2) Columnar (Fig. 2.3) Columnar with goblet cells (Fig. 2.4) Stratified squamous non-keratinised (Fig. 2.5) Stratified squamous keratinised (Fig. 2.6) Transitional (Fig. 2.7)

Label the following histological slides. EPITHELIUM TISSUE Squamous Epithelium

Facts to Remember

1. Flattened cells lining the lung alveoli 2. Capillaries in between the alveoli 3. Squamous cells permit exchange of gases Fig. 2.1: Alveoli of lung (H&E stain)

4

Microscopic Study of Epithelial and Connective Tissues

Cuboidal Epithelium

Facts to Remember

1. The cells have same width and height 2. The cells contain a central nucleus 3. All the cells rest on the basement membrane Fig. 2.2: Thyroid gland (H&E stain)

Columnar Epithelium

Facts to Remember

1. The cells are three times taller than their width 2. Nucleus is basal and oval in shape 3. All the cells look alike Fig. 2.3: Lining of stomach (H&E stain)

5

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Human Anatomy and Physiology:  Practical Workbook

Columnar Epithelium with Goblet Cells

Facts to Remember

1. The columnar cells are interrupted due to presence of empty-looking goblet cells 2. The goblet cells contain basal peripheral nucleus 3. Goblet cells secrete mucus Fig. 2.4: Small intestine (H&E stain)

Stratified Squamous Non-keratinised Epithelium

Facts to Remember

1. Basal layer formed of columnar cells 2. Intermediate layers formed of polygonal cells 3. Superficial layers formed of squamous cells Fig. 2.5: Oesophagus (H&E stain)

Microscopic Study of Epithelial and Connective Tissues

7

Stratified Squamous Keratinised Epithelium

Facts to Remember

1. Columnar cells of stratum basale rest on the basement membrane 2. Stratum spinosum, stratum granulosum, stratum lucidum and stratum corneum form the succeeding layers 3. Stratum corneum is the waterproof layer Fig. 2.6: Skin (H&E stain)

Transitional Epithelium

Facts to Remember

1. The bright active luminal cells are umbrella-shaped, some are binucleated 2. The pear-shaped cells form intermediate layer 3. The basal cells are cuboidal in shape Fig. 2.7: Urinary bladder (H&E stain)

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Human Anatomy and Physiology:  Practical Workbook

CONNECTIVE TISSUE (SPECIALISED) Hyaline Cartilage

Facts to Remember

1. Perichondrium seen all around 2. Ground substance appears homogeneous 3. Chondrocytes in lacuna lie in groups of 2–4 cells Fig. 2.8: Trachea (H&E stain)

Elastic Cartilage

Facts to Remember

1. Perichondrium seen 2. Short yellow elastic fibres 3. Single chondrocyte seen in lacuna Fig. 2.9: Epiglottis (H&E stain)

Microscopic Study of Epithelial and Connective Tissues

Fibrocartilage

Facts to Remember

1. Collagen fibres in bundles 2. A few chondrocytes in between 3. No perichondrium Fig. 2.10: Fibrocartilage (H&E stain)

BONE Compact Bone

Facts to Remember

1. Outer periosteum seen 2. Three types of lamellae seen: Haversian, interstitial and circumferential 3. In between lamellae are osteocytes in the lacuna with canaliculi Fig. 2.11: Compact bone (H&E stain)

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Human Anatomy and Physiology:  Practical Workbook

Cancellous Bone

Facts to Remember

1. Periosteum on the outside 2. Bony trabeculae with osteocytes and a few osteoblast cells 3. Marrow space in between bony trabeculae Fig. 2.12: Sternum (H&E stain)

Microscopic Study of Muscular and Nervous Tissues Muscular Tissue

Nervous Tissue





a. Striated (Fig. 3.1) b. Smooth (Fig. 3.2) c. Cardiac (Fig. 3.3)

a. b. c. d. e.

Neuron and neuroglia (Fig. 3.4) Spinal cord (Fig. 3.5) Nerve trunk (haematoxylin and eosin stain) (Fig. 3.6) Cerebellum (Fig. 3.7) Cerebrum (Fig. 3.8)

Label the following histological slides. MUSCULAR TISSUE Skeletal Muscle

Facts to Remember

1. Transverse and longitudinal striations 2. Dark and light bands 3. Multiple peripheral, flattened nuclei Fig. 3.1: Biceps brachii muscle (H&E stain)

11

3

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Human Anatomy and Physiology:  Practical Workbook

Smooth Muscle

Facts to Remember

1. Longitudinal striations 2. Single central nucleus 3. Transverse section shows round/oval fibres Fig. 3.2: Stomach (H&E stain)

Cardiac Muscle

Facts to Remember

1. Faint longitudinal and transverse striations 2. Branching muscle fibres 3. Presence of intercalated discs Fig. 3.3: Heart (H&E stain)

Microscopic Study of Muscular and Nervous Tissues

NERVOUS TISSUE Neuron and Neuroglia

Facts to Remember

1. Multipolar neuron is large irregular cell with central nucleus 2. Has multiple dendrites, single axon 3. Also seen are the astrocyte, oligodendrocyte, microglia, capillaries Fig. 3.4: Neuron and neuroglia (H&E stain)

Spinal Cord

Facts to Remember

1. Inner grey matter contains cell bodies of neurons 2. Outer white matter contains processes of neurons and neuroglial cells 3. Central canal lies in the grey commissure Fig. 3.5: Spinal cord (H&E stain)

13

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Human Anatomy and Physiology:  Practical Workbook

Nerve Trunk

Facts to Remember

1. The neurilemma is stained pink 2. The empty circle is the unstained myelin sheath 3. The inner structure is the stained axon Fig. 3.6: Median nerve (H&E stain)

Cerebellum

Facts to Remember

1. Outer molecular layer and inner granular layer 2. Purkinje’s cells at the junction 3. Uniform structure Fig. 3.7: Cerebellum (H&E stain)

Microscopic Study of Muscular and Nervous Tissues

Cerebrum

Facts to Remember

1. Six layers of cells and fibres 2. Pyramidal cells more in motor cortex and granular cells more in sensory cortex 3. Numerous capillaries present Fig. 3.8: Cerebrum (H&E stain)

15

4 Identification of Axial Bones STUDY OF HUMAN SKELETON Lateral View of Skull Label the various bones seen in the lateral view of skull.

Fig. 4.1: Bones of skull

16

Identification of Axial Bones

CRANIAL FOSSAE • Name the contents of anterior cranial fossa. • Name the contents of middle cranial fossa, including the hypophyseal fossa. • Name the contents of posterior cranial fossa.

Fig. 4.2: Cranial fossae

• Enumerate important structures passing through foramen magnum.

17

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Human Anatomy and Physiology:  Practical Workbook

VERTEBRAL COLUMN Label the various types of vertebrae with their numbers. • Name three functions of vertebral column. • Label other structures.

Fig. 4.3: Vertebral column

Name the parts of typical vertebra

Fig. 4.4: Typical vertebra

Identification of Axial Bones

Name the parts of vertebrae and important joints between C1 and C2 vertebrae

Fig. 4.5: 1st and 2nd cervical vertebrae

THORACIC CAGE • Name the functions of ribs and sternum. • Label the bones of thoracic cage.

Fig. 4.6: Bones of the thoracic cage

19

5

Identification of Appendicular Bones

SKELETON • Label the bones of upper and lower limbs in the diagram.

• Enumerate four functions of skeleton.

Fig. 5.1: Skeleton

20

Identification of Appendicular Bones

UPPER LIMB • Label the encircled joints of upper limb as shown in Fig. 5.2.

Fig. 5.2: Bones of upper limb

Bones of the upper limb are: • Clavicle – 1 • Scapula – 1 • Humerus – 1 • Radius – 1 • Ulna – 1 • Carpal bones – 8 • Metacarpals – 5 • Phalanges – 14

21

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Human Anatomy and Physiology:  Practical Workbook

LOWER LIMB • Label the encircled joints of lower limb as shown in Fig. 5.3.

Bones of the lower limb are: • Hip bone – 1 • Femur – 1 • Patella – 1 • Tibia – 1 • Fibula – 1 • Tarsals bones – 7 • Metatarsal – 5 • Phalanges – 14

Fig. 5.3: Bone of lower limb

6 Introduction to Hemocytometry Improved version of Neubauer chamber: This is a single, thick glass slide. At the cen­tre, H-shaped groove is present. H-shaped groove divides central part into two equal platforms. The central platform is 0.1 mm lower than the two pillars present laterally from the central platform. One cover slip is enough to cover half of the central platform and the depth under the cover is 0.1 mm (Fig. 6.2). Two counting grids are engraved in central platform (one in each half). These counting grids are used for TLC and total RBC counts in blood. The area of each coun­ting grid is a square measuring 3 × 3 mm2. This area is divided into nine large squares, each having an area of 1 mm2. The four large corner squares (1 mm2 each) are used for total WBC count while the central large­square (1 mm2) is used for total RBC count (Fig. 6.3). Each large corner square (WBC counting chambers) is further subdivided into 16 small squares, each measuring 1/16 mm2. The central RBC counting chamber is divided into 25 medium-sized squares, each measuring 1/25 mm2. Out of 25 medium-sized squares, only 5 medium-sized squar­es are used for RBC counting. The four corner medium-sized squares and the central medium-sized squares are used.

PRINCIPLE Blood is diluted with Turk’s fluid or WBC diluting fluid. Glacial acetic acid of WBC dilu­ting fluid destroys the membrane of red blood cells and gentian violet (another component of WBC diluting fluid) stains the nuclei of WBCs. After charging this mixture into counting chamber of improved version of Neubauer chamber, counting is done under low power objective lens of micro­scope. With the knowledge of the volume of the fluid examined and dilution of the blood obtained the number of leucocytes per cubic millimeter of undiluted whole blood is calculated. APPARATUS REQUIRED Microscope, haemocytometer (Fig. 6.1) (only improved version of Neubauer chamber and WBC pipette), watch glass, cover slip, WBC dilut­ing fluid (Turk’s fluid), cotton swab dry, cotton swab soaked in alcohol, sterile lancet or pricking needle. Composition of Turk’s fluid or WBC dilut­ing fluid: Glacial acetic acid, gentian violet and distilled water. Glacial acetic acid destroys the membrane of red blood cells. Gentian violet stains the nuclei of WBCs.

6.1: Hemocytometer with RBC and WBC pipettes

Fig. 6.2: Improved version of Neubauer chamber

23

24

Human Anatomy and Physiology:  Practical Workbook

Fig. 6.3: Counting grids

Each medium-sized square is further divi­ded into 16 smallest squares. Total 400 smallest squares are present in the central large square. The area of each smallest square is 1/400 mm2. The red cells are counted in 80 smallest squares, i.e. 5 medium-sized squares. WBC pipette: Three markings are present in WBC pipette (Fig. 6.4). Two markings, i.e. 0.5 and 1 are present in the stem part of pipette and third marking, i.e. 11 is present at neck region of pipette after the bulb. Bulb size is smaller than RBC pipette. One white bead is present inside the bulb for mixing of blood and WBC diluting fluid. The mouthpiece is white in colour. RBC pipette: Three markings are present in RBC pipette. Two markings, i.e. 0.5 and 1, are present in the stem part of pipette and third marking, i.e. 101 is present at neck region of pipette after the bulb. Bulb size is much larger than WBC pipette. One red bead is present inside the bulb for mixing of blood and Hayme’s fluid. The mouthpiece is red in colour. Fig. 6.4: WBC pipette

Enumeration of White Blood Cell Count

7

• Hold the WBC pipette at 45º angle and allow to form a small drop of diluted blood at the tip of WBC pipette.

PROCEDURE • Clean the improved Neubauer chamber, white blood cell (WBC) pipette, cover slip and watch glass, thoroughly and then dry these completely. • Take enough amount of Turk’s fluid or WBC diluting fluid in watch glass.

• Then touch the drop to the slit between counting chamber and cover slip and during the time of charging WBC pipette should be kept in 45º angle. • The chamber is filled automatically by capillary action. • When the diluted blood enter between the gap of counting chamber and cover slip, then immediately WBC pipette should be removed.

Filling of the WBC Pipette • Clean the tip of finger (never choose thumb and little finger for pricking) of non-domi­nant hand with cotton swab soaked in alcohol. • Allow the finger to air dry completely. • Squeeze that finger for few seconds just to accumulate blood at the tip of finger. • Prick the fingertip with a sterile lancet. • Discard the first drop of blood with dry cotton swab. • Make a large drop of blood on the fingertip. • Dip the tip of the WBC pipette within the blood drop. • Suck the blood exactly up to the 0.5 mark in the WBC pipette. No air bubble should be present in between the blood column. • Wipe the outside part of the pipette tip. • Suck Turk’s fluid or WBC diluting fluid up to the ‘11’ mark. • Mix the blood and Turk’s fluid by gently rotating the pipette after placing it horizontally in between the palms for at least 2 minutes.

• After charging the improved Neubauer chamber, allow it to stand for 3 to 4 minutes so that all the cells settle down otherwise one may get the faulty result (because of cell movement). COUNTING OF LEUCOCYTES • The Neubauer chamber placed in the stage of the microscope and focussed under low power objective lens (Fig. 7.1). • Then recognise WBCs. They appear as round, dark blue dots and also try to differentiate foreign particles from WBCs (if air bubbles appear then clean the cover slip, improved Neubauer chamber and charge it again). • Count in all four large corner squares (1 mm2 each). • Draw WBC squares in notebook and enter the observation and calculate the final result. Rules of Counting

Charging of the Improved Version of Neubauer Chamber

• Never tilt the microscope during counting. • WBCs which are present within the square are included in counting. • If WBCs touching or laying on the upper horizontal line and left vertical line are included in that specific square then WBCs touching or laying on the lower horizontal line and right vertical line are omitted in that specific square.

• Place a cover slip on the half part of central platform and the edge of the cover slip should be little bit outward from the end slit. • Discard first 2–3 drops of content in a dry cotton because initially the stem part of WBC pipette only contains Turk’s fluid not diluted blood. 25

Human Anatomy and Physiology:  Practical Workbook

26

Fig. 7.1: WBC counting chambers under low power objective lens



Calculations Calculation of Dilution Factor Out of the 11 parts, 0.5 part is blood and 10.5 parts is WBCs diluting fluid in the WBC pipette. But 1 part present in initial stem part of pipette is not mixed with blood. Thus, 0.5 part of the blood mixes with 9.5 parts of the WBC diluting fluid in the bulb to form 10 parts of diluted blood. Final diluted blood volume achieved (10 parts)



Final diluted blood volume achieved (10 parts) Dilution factor =  = 20 Original blood volume taken (0.5 part)

Calculation of Volume of Large Squares • Length of one large square = 1 mm • Area of one large square = 1 × 1 mm2 • Depth when cover slip is placed = 1/10 mm2 • Volume of one large square = 1 × 1 × 1/10 = 1/10 mm3 • Volume of 4 large squares = 4 × 1/10 mm3 = 4/10 mm3

Enumeration of White Blood Cell Count

27

Calculation of Total Leucocyte Count (TLC)

WBCs present in 4/10 mm3 volume of diluted blood = N (say) Therefore, cells in 1 mm3 volume of diluted blood = N × 10/4 Therefore, cells in 1 mm3 volume of undiluted blood = N × 10/4 × 20 = N × 50 = X (say) So, total leucocyte count is X/mm3.

Normal Value of Total Leukocyte Count (TLC) Adults : 4,000–11,000/mm3 of the blood Newborns : 10,000–25,000/mm3 of the blood Infants : 6,000–18,000/mm3 of the blood Children : 5,000–15,000/mm3 of the blood Note : TLC not differs with gender unlike RBC count. PRINCIPLE OF PERIPHERAL BLOOD SMEAR Peripheral blood smear is prepared and stained with Leishman’s stain. Different types of leucocytes are identified under oil immersion microscope and 100 leucocytes are counted to determine the differential leucocyte count. Apparatus Requirements Glass slides, dry cotton swab, cotton swab soaked in alcohol, sterile lancet or pricking needle, Leishman’s stain, distilled water or buffer solution, Pasteur pipette, compound microscope. Leishman’s Stain It comprises methy­lene blue, eosin and methyl alcohol. Methylene blue: It is a basic dye and stains acidic parts of cells, e.g. nucleus of WBCs and cytoplasmic granules of basophils and cyto­plasm of most of the WBCs except eosino­phil. Eosin: It is an acidic dye and stains basic parts of cells, e.g. cytoplasm of RBCs and eosino­­phils and cytoplasmic granules of eosinophils. Methyl alcohol: It helps in preservation and fixation of blood smear with slide. PROCEDURE Preparations of Peripheral Blood Smear • Take two clean glass slides (Fig. 7.2). • Grease free glass slides by washing these with soap water and dry completely. • Then select one slide as spreader. The narrow edge of spreader should be smooth. • Clean the tip of finger (never choose thumb and little finger for pricking) of non-dominant hand with cotton swab soaked in alcohol. • Allow the finger to air dry completely.

Fig. 7.2: Steps of peripheral blood smear preparation

• Squeeze that finger for few seconds just to accumulate blood at the tip of finger. • Prick the fingertip with a sterile lancet. • Discard the first drop of blood with dry cotton swab. • Place a drop of blood on one end of a slide and it should be about 1 cm away from the narrow edge of one end (Fig. 7.2A) (Step 1). • The blood drop was placed by touching the blood drop to the slide. • Keep the slide on working table and hold the slide firmly with the middle or index finger and thumb of the non-dominant hand at the end part of the slide. • Hold the spreader with dominant hand from its long edge with the help of middle or index finger and thumb. • Place the spreader slide just in front of the blood drop at an approximate 45° angle (Fig. 7.2B) (Step 2). • Pull the spreader in backward direction until it touches the blood drop and hold for few seconds at that place to spread the blood along the narrow edge of the spreader. The spreader can be slightly moved inside by side direction to accelerate the spreading of blood along the narrow edge (Fig. 7.2C) (Step 3). • Then pull the spreader in the forward direc­t ion (towards the other end of the slide) by maintaining approximate 45° angle till the end and pressure should be gentle and pulling should be uninterrupted and little bit quick (Fig. 7.2D) (Step 4). • Dry the peripheral blood smear completely (Fig. 7.3).

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Human Anatomy and Physiology:  Practical Workbook

Fig. 7.2A: Step 1

Fig. 7.3: Step 5

Examination of the Stained Blood Smear

Fig. 7.2B: Step 2

Fig. 7.2C: Step 3

Fig. 7.2D: Step 4

Fixation and Staining of Peripheral Blood Smear • Place the peripheral blood smear slide on the staining rack. The smear side should be facing upside. • Pour few drops of Leishman’s stain on the smear. The stain should be poured just to cover the smear and stain drops should be counted. • Then wait for 2 minutes. The waiting time depends upon the stain concentration. • Add distilled water or buffer solution with the help of Pasteur pipette on the smear. The number of drops of distilled water should be double as that of stain and if buffer solution is used then it should be same as that of stain. It should be taking care that the water or buffer solution does not spill out. • Mix the stain and the water evenly by blow­ing air gently from mouth or by blowing air through a Pasteur pipette. • Then wait for 10 minutes again that waiting time depends on stain concentration. • Pour the stain and wash the slide gently under very slow speed tap water and place one finger at the upper part of the slide to prevent from direct flow of tap water on the smear and complete washout. • Dry it completely and then observe under microscope.

Scanning the Whole Smear • First, scan the prepared stained blood smear under low power objective lens as quickly as possible. • The extreme initial part (head part) and extreme end part (tail part) of the smear should not be included for counting. Because smear is very thick in the initial portion and blood cells are unevenly distributed in this part and there is clumping of RBCs. At the end part, cells are also distri­buted unevenly and larger leucocytes, e.g. monocytes and eosinophils are high in number. So, both the places should be avoi­ded for differential leucocyte count (DLC). • The middle part should be always chosen for DLC as in this part smear is thin enough (one cell thickness) and blood cells are evenly distributed. Selection of Site and Perform Differential Leucocyte Count • Then switch the low power objective lens to oil immersion objective lens. • Place one drop of cedar wood oil on the selected part of the smear. • Make close contact the oil immersion objective lens with cedar wood oil. • Use plane or concave mirror to get the light. • Move the condenser at the uppermost position. • Iris diaphragm should be fully opened to get maximum intensity of illumination. • After selection of the part, differential leuco­c yte count starts from one end of the smear and proceed in a zigzag manner. No area should be repeated for counting. • Place a drop of immersion oil on the slide (do not place on a cover slip) directly on the smear. Now, switch to oil immersion objec­tive lens. Move coarse adjusting screw, by seeing from the outside of microscope till the lens is immersed in the drop of cedar wood oil. • Condenser should be at highest position and iris diaphragm should be opened com­pletely. • Then observe through eyepiece lens and focus the film by using fine adjustment screw. • Identify different types of leucocytes by comparing with identifying character of leucocytes given in Table 7.1.

Enumeration of White Blood Cell Count

• Count at least 100 leucocytes by tally bar count or with the help of manual cell counter. • Determine the percentage of the various types of leucocytes. For counting the cells, start from one end of the smear and proceed in a zigzag manner.

29

Normal Values of Different Leucocytes Neutrophils Eosinophils Basophils Lymphocytes Monocytes

: 50–70% : 1–4% : 0–1% : 20–40% : 3–8%

Table 7.1: Characteristics feature of erythrocytes and leucocytes Types of cells

Cell size Characteristic features of (µm) nucleus

Characteristic features of cytoplasm

Characteristic features of cytoplasmic granules

RBC

7.2

• Mature RBC devoid of nucleus

Pinkish in colour Pale at the centre and peripheral part is little darker

Cytoplasmic granules absent

Neutrophil (polymorph) (Fig. 7.4A)

10–14

• Deep violet or deep bluish in colour • Multi-lobed nucleus (2–6 lobes) and these lobes are connected by chromatin threads

Light bluish in colour

Fine cytoplasmic granules, pink and blue both coloured granules are present (take both types of stains, almost 50% are eosinophilic and rest 50% are basophilic in nature) (Fig. 7.4B)

Fig. 7.4A

Eosinophil (Fig. 7.5A)

10–15

• Deep violet or deep Light pinkish in colour bluish in colour • Bi-lobed nucleus (very few tri-lobed nucleus are visible) • It is headphone-shaped

10–14

• Deep violet or deep bluish in colour • “S” shaped • Nucleus not visible because of high concentration of cytoplasmic granules

Light bluish in colour

7–10

• Deep violet or deep bluish in colour • Large and single • Almost cover the whole cell

• Light bluish in colour Cytoplasmic granules are • Amount of cytoplasm is very absent (Fig. 7.7B) scanty and hardly visible

10–14

• Deep violet or deep bluish in colour • Large and single • Present at the centre • Almost circular or oval

• Light bluish in colour Cytoplasmic granules are • Amount of cytoplasm is very absent (Fig. 7.8B) scanty and hardly visible

Fig. 7.6A

Small lymphocyte (Fig. 7.7A)

Fig. 7.6B

(Fig. 7.8A)

Fig. 7.8B

Fig. 7.8A

Monocyte (Fig. 7.9A)

Fig. 7.9A

Coarse cytoplasmic granules, blue in colour (basophilic in nature) These cytoplasmic granules crowded all over the cell that is why nucleus not visible (Fig. 7.6B)

Fig. 7.7B

(Fig. 7.7A)

Large lymphocyte

Coarse cytoplasmic granules, pinkish in colour (eosinophilic in nature) (Fig. 7.5B)

Fig. 7.5B

Fig. 7.5A

Basophil (Fig. 7.6A)

Fig. 7.4B

15–18

• Deep violet or deep bluish in colour • Large and single • Kidney or bean-shaped • Eccentric or placed at the periphery

• Light bluish in colour • Abundant amount

Cytoplasmic granules are absent (Fig. 7.9B)

Fig. 7.9B

30

OBSERVATION EXERCISE

Human Anatomy and Physiology:  Practical Workbook

Enumeration of Total RBC Count

8

sized squares and the central medium-sized squares are used (Fig. 8.1). Each medium-sized square is further divided into 16 smallest squares. Each central large square has 400 smallest squares. The area of each smallest square is 1/400 mm2. The red cells are counted in 80 smallest squares, i.e. 5 medium-sized squares. RBC pipette: Three markings are present in RBC pipette (Fig. 8.2). Two, i.e. 0.5 and 1 are present in the stem part of pipette and third marking, i.e. 101 is present at neck region of pipette after the bulb. Bulb size is much larger than WBC pipette. One red bead is present inside the bulb for mixing of blood and Hayem’s fluid. The mouthpiece is red in colour.

PRINCIPLE Blood is diluted 200 times with Hayem’s fluid or RBC diluting fluid. After charging this mixture into counting chamber of improved version of Neubauer chamber, counting is done under high power objective lens of microscope. With the knowledge of the volume of the fluid examined and dilution of the blood obtained, the number of erythrocytes per cubic millimeter of undiluted blood is calculated. APPARATUS REQUIRED Microscope, haemocytometer (only improved version of Neubauer chamber and RBC pipette), watch glass, cover slip, RBC dilu­ting fluid (Hayem’s fluid), dry cotton swab, cotton swab soaked in alcohol, sterile lancet or pricking needle. Composition of Hayem’s fluid or RBC dilu­ting fluid: Sodium sulphate 2.5 gm, sodium chloride 0.5 gm, mercuric chloride 0.25 gm (corrosive sublimate), distilled water to make-up to 100 ml. Improved version of Neubauer chamber: This is a single, thick glass slide. At the centre, H-shaped groove is present. H-shaped groove divides central part into two equal platforms. The central platform is 0.1 mm lower than the two pillars present laterally from the central platform. One cover slip is enough to cover half of central platform and the depth under the cover is 0.1 mm. Two counting grids are engraved in central platform (one in each half). These counting grids are used for TLC and total RBC counts in blood. The area of each counting grid is a square measuring 3 × 3 mm2. This area is divi­ded into nine large squares, each having an area of 1 mm2. The four large corner squares (1 mm2 each) are used for WBC count while the central large square (1 mm2) is used for RBC count. The central RBC counting chamber is divided into 25 medium-sized squares each measuring 1/25 mm2. Out of 25 medium-sized squares only 5 medium-sized squares are used for RBC counting. The four corner medium-

PROCEDURE • Clean the improved Neubauer chamber, RBC pipette, cover slip and watch glass, thoroughly and then dry these completely. • Take enough amount of Hayem’s fluid or RBC diluting fluid in watch glass. Filling of the RBC Pipette • Clean the tip of finger (never choose thumb and little finger for pricking) of non-dominant hand with cotton swab soaked in alcohol. • Allow the finger to air dry completely. • Squeeze that finger for few seconds just to accumulate blood at the tip of finger. • Prick the finger tip with a sterile lancet. • Discard the first drop of blood with dry cotton swab. • Make a large drop of blood on the finger. • Dip the tip of the RBC pipette within the blood drop. • Suck the blood exactly up to the 0.5 mark in the RBC pipette. No air bubble should be present in between the blood column. • Wipe the outside part of the pipette tip. 31

32

Human Anatomy and Physiology:  Practical Workbook

Fig. 8.1: RBC counting chambers in improved version of Neubauer chamber

• Suck Hayem’s fluid or RBC diluting fluid up to the 101 mark. • Mix the blood and Hayem’s fluid by gently rotating the pipette after placing it hori­zon­tally in between the palms for at least 2 minutes. Charging of the Improved Version of Neubauer Chamber

Fig. 8.2: RBC pipette

• Place a cover slip on the half part of central platform and the edge of the cover slip should be little bit outward from the end slit. • Discard first 2–3 drops of content in a dry cotton because initially, the stem part of RBC pipette only contains Hayem’s fluid not diluted blood.

Enumeration of Total RBC Count

• Hold the RBC pipette at 45º angle and allow to form a small drop of diluted blood at the tip of RBC pipette. • Then touch the drop to the slit between counting chamber and cover slip and during the time of charging RBC pipette should be kept in 45º angle. • The chamber is filled automatically by capillary action. • When the diluted blood enters between the gap of counting chamber and cover slip then immediately RBC pipette should be removed. • After charging the improved Neubauer chamber, allow it to stand for 3 to 4 minutes so that all the cells

33

settle down otherwise one may get the faulty result (because of cell movement). Counting of RBC Examine • The Neubauer chamber placed in the stage of the microscope and focussed under low power objective lens to confirm whether uniformly RBCs are distributed or not. • Then counting of RBCs done under high power objective lens.

Fig. 8.3: RBC counting chambers under high power objective lens

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Human Anatomy and Physiology:  Practical Workbook

• Then recognise RBCs. They appear as transparent circular cell and also try to differentiate foreign particles from RBCs (if air bubbles appear then clean the cover slip, improved Neubauer chamber and charge it again). • The four corner medium-sized squares and the central medium-sized squares are used for counting RBCs. (The central RBC coun­ting chamber is divided into 25 medium-sized squares. Out of 25 medium-sized squares only 5 medium-sized squares are used for RBC counting.) • Draw RBC counting chamber squares in notebook and enter the observation and calculate the final result (Fig. 8.3). Rules of Counting • Never tilt the microscope during counting. • RBCs which are present within the square are included in counting. • If RBCs touching or laying on the upper horizontal line and left vertical line are included in that specific square then RBCs touching or laying on the lower horizontal line and right vertical line are omitted in that specific square. CALCULATIONS Calculation of Dilution Factor Out of the 101 parts, 0.5 part is blood and 100.5 parts are RBCs diluting fluid in the RBC pipette. But 1 part present in initial stem of pipette is not mixed with blood. Thus, 0.5 part of the blood mixes with 99.5 parts of the RBC diluting fluid in the bulb to form 100 parts of diluted blood. OBSERVATION EXERCISE



Final diluted blood volume achieved (100 parts) Dilution factor =  = 200 Original blood volume taken (0.5 part)

Calculation of Volume of Large Squares • Length of one medium square = 1/5 mm • Area of one medium square = 1/5 × 1/5 mm = 1/25 mm2 • Depth when cover slip is placed = 1/10 mm2 • Volume of one medium square = 1/5 × 1/5 × 1/10 = 1/250 mm3 • Volume of 5 medium squares = 5 × 1/250 mm3 = 1/50 mm3. Calculation of Total Erythrocyte Count • RBCs present in 1/50 mm3 volume of diluted blood = N (say) • Therefore, RBCs present in 1 mm3 volume of diluted blood = N × 50 • Therefore, RBCs present in 1 mm 3 volume of undiluted blood = N × 50 × 200 = N × 10000 = X (say) So, total erythrocyte count is X/mm3. Normal Value of Total Erythrocyte Count • Adult males: 5–6 million/µl (average 5.5 million/µl). • Adult females: 4.5–5.5 million/µl (average 5.5 million/µl).

Determination of Bleeding Time PRINCIPLE

9

• Remove the drops of blood after every 15 seconds by touching the skin gently with a filter paper and number the blood spots 1 onwards.

After a deep skin puncture with a pricking needle, bleeding will continue for few minutes and then stops. The time interval between the skin puncture and the stoppage of bleeding is bleeding time (BT). The BT depends on vaso­constriction and platelet plug formation. It determines the function of platelets and integrity of the capillaries.

• Note the time when there is no trace of blood on the filter paper, i.e. when bleeding completely stopped. • Count the number of blood spots on the filter paper and multiply by 15 seconds to get the bleeding time. • Enter the observation in notebook (Fig. 9.1). Normal value of bleeding time: 1–5 minutes in Duke’s method.

Methods of Determination of BT Two methods are used to determine BT:

Ivy’s Method

1. Duke’s method Duke method is usually preferred in clinical laboratories even though the Ivy method is more reliable one.

Apparatus required: Sterile lancet or prick­ing needle, dry cotton swab, cotton swab soaked in alcohol, beaker containing water at 37�C (placed in water bath to maintain this parti­cular temperature), water bath and stopwatch.

Duke’s Method

Procedure of Ivy’s Method

Apparatus required: Sterile lancet or pric­king needle, dry cotton swab, cotton swab soaked in alcohol, filter paper and stop­watch.

• Clean the tip of finger (never choose thumb and little finger for pricking) of non-dominant hand with cotton swab soaked in alcohol.

Procedure of Duke’s Method

• Squeeze that finger for few seconds just to accumulate blood at the tip of finger.

• Clean the tip of finger (never choose thumb and little finger for pricking) of non-dominant hand with cotton swab soaked in alcohol.

• Prick the fingertip with a sterile lancet and puncture should be deep enough (at least 3 mm deep).

• Allow the finger to air dry completely. • Squeeze that finger for few seconds just to accumulate blood at the tip of finger.

• Dip the pricked finger in a beaker containing water at 37ºC and placed in water bath to maintain the temperature at this particular point.

• Prick the fingertip with a sterile lancet and puncture should be deep enough (at least 3 mm deep).

• The blood flows to the bottom of the beaker in a continuous slow stream.

• Immediately start stopwatch.

• Note the time when the bleeding stops spontaneously.

2. Ivy’s method

• Allow the finger to air dry completely.

• Immediately start stopwatch.

35

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Human Anatomy and Physiology:  Practical Workbook

Fig. 9.1: Determination of bleeding time

• The time interval between the skin puncture and the stoppage of bleeding is bleeding time.

OBSERVATION EXERCISE

• Enter the observation in notebook. Normal value of bleeding time: 2–6 minutes in Ivy’s method.

Determination of Clotting Time PRINCIPLE

10

• Allow the finger to air dry completely. • Squeeze that finger for few seconds just to accumulate blood at the tip of finger. • Prick the fingertip with a sterile lancet. • Discard the first drop of blood. • Make a large drop of blood on the finger. • Dip one end of a clean and dry capillary tube within the blood drop and other end of capillary tube should kept little bit lower from horizontal position. • Blood will fill the tube by capillary action. • Start stopwatch from the moment when capillary tube filling started. • After 30 seconds break off a small piece of capillary tube (about 1 cm) from the end which is filled first with the help of index finger and thumb of two hands and carefully look for fibrin thread. • Repeat this process after every 30 seconds till the appearance of fibrin thread. • Note the time of the point when fibrin thread is seen between the broken ends of the capillary tube. • Count the number of broken pieces of capillary tube and multiply by 30 seconds to get the clotting time (this is the time interval between starting of collection of blood in capillary tube and the appearance of fibrin thread) (Fig. 10.1). • Enter the observation in notebook. Normal value of clotting time: 3–9 minutes by Wright’s capillary tube method.

If blood is kept in a glass capillary or a test tube then blood coagulates into a jelly-like mass. The time interval between the collec­tion of blood within the capillary tube and clot formation is clotting time (CT). The CT depends on coagulation mechanism (Fig. 10.1). Methods of Determination of CT Two methods are used to determine CT: 1. Wright’s capillary tube method 2. Lee-White test tube method. The capillary tube method is the most com­monly used in determination of CT. Wright’s Capillary Tube Method Apparatus required: Sterile lancet or prick­ing needle, dry cotton swab, cotton swab soaked in alcohol, capillary tube and stop­watch. Procedure of Wright’s Capillary Tube Method • Clean the tip of finger (never choose thumb and little finger for pricking) of non-dominant hand with cotton swab soaked in alcohol.

Lee and White Test Tube Method Apparatus required: Sterile 5 ml syringe with needle, dry cotton swab, cotton swab soaked in alcohol, three clean and dry small test tubes, beaker containing water at 37ºC (placed in water bath to maintain this parti­cular temperature), water bath and stop­watch. Procedure of Lee and White Test Tube Method • Take three clean and completely dry small test tubes and label them as 1, 2 and 3.

Fig. 10.1: Determination of clotting time

37

38

Human Anatomy and Physiology:  Practical Workbook

• Draw 5 ml blood from anticubital vein by venepuncture with the help of 5 ml sterile syringe with needle.

• Note the time gap and this is the clotting time for first (1) test tube.

• Start the stopwatch when blood stars entering in the syringe.

• Then take the test tube labelled as 2 and tilt it as before till the blood clots.

• Transfer immediately 1.5 ml of collected blood into each of the clean dry test tubes.

• Note the time gap and this is the clotting time for second (2) test tube.

• Place these three test tubes in a beaker containing water at 37ºC.

• Then same method should be followed with the third test tube, i.e. labelled as 3.

• Then leave this beaker in water bath at 37ºC to maintain the temperature of the beaker.

• Note the time gap and this is the clotting time for third (3) test tube.

• After one minute, take out the test tube labelled as 1 and tilt that at 45° of angle. If blood spills, then keep the test tube back in the water bath. • Repeat the process in every 30 seconds gap with that particular test tube (labelled as 1) till the point when tilting of the test tube is possible without spilling of blood.

OBSERVATION EXERCISE

• Clotting time of third test tube should be considered as the final result. Because coagulation process is accelerated by repeated tilting and the third test tube is tilted for lesser time. • Enter the observation in notebook. Normal value of clotting time: 5–10 minutes by Lee and White test tube method.

Estimation of Haemoglobin Concentration

11

PRINCIPLE N/10 HCl breaks the membrane of erythro­c ytes. Then haemoglobin present within the erythrocytes converted into acid haematin by reaction with N/10 HCl. The acid haematin is brown in colour. It is necessary to allow it stand for 10 minutes before dilution, so that all the haemoglobin present in 20 µl blood is converted into acid haematin. This solution is further diluted until its colour is matched visually with the standard coloured glass rods of Sahli’s comparator. The haemoglobin concen­tration is measured directly from the Sahli’s graduated tube. Apparatus Required Sahli’s haemoglobinometer or haemometer, N/10 HCl, distilled water, cotton swab dry, cotton swab soaked in alcohol, sterile lancet or pricking needle. Sahli’s haemoglobinometer or haemometer: It contains a Sahli’s comparator, graduated tube, haemoglobin pipette, stirrer and dropper (Fig. 11.1). Comparator: It has three columns of slots. Two lateral columns are covered and fitted with nonfading brown-tinted glass rods standardised against acid haematin. At the middle portion of three columns there is a vacant slot which accommodates the Sahli’s graduated tube. At the back side of this comparator an opaque white glass is attached (Fig. 11.2). Graduated tube: Two types of marking or graduations are there. At one side gram percent (gm%) markings (2 to 22 gm%) are present, and on the other side percentage (%) markings (10 to 140%) are present. Each small marking in gram% scale denotes 0.2 gram% and in % scale denotes 1%. Out of the two scales, gram% is always preferred over % scale (Fig. 11.3). Haemoglobin pipette: This pipette has only one marking of 20 µl (20 mm3) and no bulb is present in this pipette (Fig. 11.4).

Fig. 11.1: Sahli’s haemometer

Stirrer: It is a thin glass rod for mixing the solution during dilution with distilled water. PROCEDURE • Sahli’s graduated tube and haemoglobin pipette should be completely dry before starting the work. • Take N/10 HCl up to 2 gram% mark or 20% mark with the help of a dropper. • Clean the tip of finger (never choose thumb and little finger for pricking) of non-domi­nant hand with cotton swab soaked in alcohol. • Allow the finger to air dry completely. • Squeeze that finger for few seconds just to accumulate blood at the tip of finger. • Prick the fingertip with a sterile lancet. • Discard the first drop of blood with dry cotton swab. • Make a large drop of blood on the finger. 39

40

Human Anatomy and Physiology:  Practical Workbook

Fig. 11.4: Haemoglobin pipette

Fig. 11.2: Sahli’s comparator

Fig. 11.3: Sahli’s graduated tube percentage marking

• Dip the tip of the pipette within the blood drop. • Suck the blood exactly up to the mark of 20 mm3 or 20 µl in the haemoglobin pipette. No air bubble should be present in between the blood column of haemoglobin pipette. • Wipe the outside part of the pipette tip. • Then gently blow the blood of haemoglobin pipette into the graduated tube containing N/10 HCl.

• Rinse the pipette with the N/10 HCl of the graduated tube at least for two times and take out the pipette from graduated tube. • Rotate the graduated tube for few seconds keeping it in between the palms to mix the blood properly with N/10 HCl. • Allow the graduated tube to stand for about 10 minutes so that all haemoglobin present in 20 µl blood is converted into acid haematin. • After 10 minutes dilute the acid haematin solution by adding distilled water drop by drop with the help of a dropper. • Mix it with the help of a stirrer and match the colour of the solution in the tube with the standards browntinted glass rods of the comparator. • Add distilled water till the colour is not matched with standards brown-tinted glass rods of the comparator and the stirrer should be kept above the solution while matching the colour with comparator. Do not take it out from the graduated tube until the final reading is taken. • When colour matched, remove the stirrer from graduated tube. • Hold the graduated tube at your eye level and the graduated tube should be hold in such a way that the graduation on it do not face directly in front side and interfere in the matching of colour. • Note the reading by looking at the gram% marking where lower meniscus of this transparent colour solution touched the graduated tube (if % scale is taken then 14.8 gm/dl should be consider as 100% irrespective of gender and % value should be taken in similar way). Normal Haemoglobin Concentration In gram% scale: Adult males : 14–18 gm/dl (average 15.5 gm/dl) Adult females : 12.5–15.5 gm/dl (average 13.5 gm/dl) In % scale: 14.8 gm/dl considered as 100% irrespective of gender.

Estimation of Haemoglobin Concentration

OBSERVATION EXERCISE

41

12 Determination of Blood Group PRINCIPLE

(anti-Rh) serum [containing monoclonal anti-Rh (D) antibodies] (Fig. 12.1), watch glass, four slides, 0.9% saline, applicator sticks, Pasteur pipette and compound microscope.

Blood group antigens or agglutinogens are present on the surface of red cell membrane and blood group antibodies or agglutinins are present in the plasma. The principle of blood group determination is dependent on the result of reaction between the commercially available three types of antisera (each containing specific type of agglutinin) and with the subject’s red blood cells (containing blood group agglutinogens). Presence or absence of agglutination after antigen–antibody reaction determines the subject’s blood group.

PROCEDURE • Take four grease free clean glass slides. • Mark four glass slide as A (for anti-A), B (for anti-B), D (for anti-D) and C (for control) by using glass marking pen. • Take 2 ml of 0.9% saline in a clean watch glass. • Clean the tip of finger (never choose thumb and little finger for pricking) of non-dominant hand with cotton swab soaked in alcohol.

APPARATUS REQUIRED Sterile lancet or pricking needle, dry cotton swab, cotton swab soaked in alcohol, glass marking pen, anti-A serum (containing monoclonal anti-A antibodies, anti-B serum (containing monoclonal anti-B antibodies), anti-D

• Allow the finger to air dry completely. • Squeeze that finger for few seconds just to accumulate blood at the tip of finger. • Prick the fingertip with a sterile lancet. • Discard the first drop of blood. • Place a large drop of blood to the 0.9% saline kept in a clean watch glass (blood drops should not be added directly from the finger prick to the antisera because it may give false result). • Put one drop of anti-A serum on the slide marked as ‘A’. • Put one drop of anti-B serum on the slide marked as ‘B’. • Put one drop of anti-D serum on the slide marked as ‘D’. • And put one drop of 0.9% saline on the slide marked as ‘C’. • After that pour a drop of red cell suspension from watch glass to each of four slides marked as ‘A’, ‘B’, ‘D’ and ‘C’ with the help of a Pasteur pipette.

Fig. 12.1: Anti-A, anti-B and anti-D monoclonal

42

Determination of Blood Group

43

• Mix the specific anti-sera and red blood cell suspension in three different slides with the help of three separate applicator sticks. • Mix the 0.9% saline on the slide marked as ‘C’ and red blood cell suspension with the help of another applicator stick. • Wait for 9–10 minutes. • After that observe by the naked eye whether any agglutination or clumping occur or not in antisera and red cell suspension mixtures in slides ‘A’, ‘B’, ‘D’ and compare it with ‘control’ mixture in slide ‘C’ (tilting or rocking the slide sometimes help in better understanding) (Fig. 12.2). • Then confirm whether any agglutination occur or not under low magnification power of compound microscope. Anti-A serum

Anti-B serum

Anti-D serum

Blood Group

+

–

+

A+

+

–

–

A–

–

+

+

B+

–

+

–

B–

+

+

+

AB+

+

+

–

AB–

–

–

+

O+

–

–

–

O–

OBSERVATION EXERCISE

Fig. 12.2: Blood group determination

• Make a table of your observation whether any agglutination occur or not with anti-A serum, anti-B serum and anti-D (anti-Rh) serum. • Interpret results as follows: Observation and Results Subject’s name:

____________________

Age: __________ Gender: Anti-A serum

__________ Anti-B serum

Anti-D serum

Blood Group

Note: Use (+) sign for presence of agglutination, use (–) sign for absence of agglutination.

13 Determination of ESR PRINCIPLE When mixture of blood and anticoagulant is allowed to stand in a very slender tube then the erythrocytes gradually settled down at the bottom part of the tube and at the upper part clear straw-coloured plasma appears. The “Rouleaux” formation, i.e. stacking of RBC on one another is the reason of sedimen­tation of erythrocytes in anti-coagulated blood kept in undisturbed condi­ tion. After “Rouleaux” formation, density of stacked erythrocytes is increased and promotes sedimentation. The rate at which erythrocytes are sedimented or settled down, is known as erythrocyte sedimen­tation rate (ESR). ESR depends upon the rate at which “Rouleaux” formation is occurring. The ESR is expressed as mm/hr. METHODS OF DETERMINATION OF ESR Two methods are used to determine ESR: 1. Westergren’s method (Fig. 13.1) 2. Wintrobe’s method (Fig. 13.4)

Fig. 13.1: Westergren’s tubes and stand

Procedure

Westergren’s Method

• Wrap the tourniquet 2 inch above the ante­cubital fossa in the upper arm. • Clean the antecubital fossa region (parti­cularly the median cubital vein region) with alcohol soaked swab. • Then dry that place completely. • Locate the median cubital vein. • Insert the needle of the syringe in median cubital vein (preferably) swiftly at an angel of 20 to 30°. • Collect 5 ml of blood by venipuncture. • Mix the 4 ml blood of the syringe with 1 ml 3.8% sodium citrate (anticoagulant) in a container. The blood and anticoagulant ratio should be 4:1. • Mixing should be done thoroughly by inversion and swirling for at least 2 minutes. • Then suck this mixture up to the 0 mark of Westergren’s tube and start stopwatch from the moment when Westergren’s tube filling started.

The Westergren’s method is more sensitive than Wintrobe’s method because the Westergren’s tube is much longer than Wintrobe’s tube. Apparatus Required Syringe (5 ml) with needle, Westergren’s pipette and stand (Fig. 13.1), Pasteur pipette, i.e. drop­per with long nose pointed tip, antico­agulant—sodium citrate (3.8 gm%), tourni­quet, dry cotton swab, cotton swab soaked in alcohol. Westergren’s Pipette It is a 30 cm long graduated tube and opened at both sides. The inner width of the tube is 2.5 mm. Graduation is present in lower two-thirds part of the tube. 0 to 200 markings are there (Fig. 13.2). 44

Determination of ESR

45

pointed tip, antico­agulant-double oxalate (ammonium oxalate + potas­sium oxalate: 6 mg + 4 mg), tourniquet, dry cotton swab, cotton swab soaked in alcohol. Wintrobe’s Pipette It is a short 11 cm graduated tube and opened only at one side. The inner width of the tube is 2.5 mm. Two similar types of graduations are present but direction is different. In one type of graduation 0 to 10 marking in upside down direction and in another type 0 to 10 marking in downside up direction (Fig. 13.4). Each small marking denotes 0.1 mm. Procedure • Wrap the tourniquet 2 inch above the ante­cubital fossa in the upper arm. • Clean the antecubital fossa region (parti­cularly the median cubital vein region) with alcohol soaked swab. Fig. 13.2: Westergren’s pipette marking

• Block tightly the upper open end with the help of thumb immediately to prevent the leaking of blood mixture from the bottom open end. • Place the lower end of Westergren’s tube in the rubber pad present at the bottom section of the Westergren’s stand and fix it vertically. The upper end of Westergren’s tube should be fixed by the metal clip or screw provided on the upper section of that stand. • Allow the tube to stand for an hour and grad­ually at the upper part clear straw-coloured plasma appears. • Note the level up to which the red cell column has fallen down after 1 hour. • Enter the observation in note book.

• Then dry that place completely. • Locate the median cubital vein. • Insert the needle of the syringe in median cubital vein (preferably) swiftly at an angel of 20 to 30º. • Collect 5 ml of blood by venipuncture. • Mix the 2 ml blood of the syringe with double oxalate anticoagulant (ammonium oxalate + potassium oxalate: 6 mg + 4 mg) in a container. • Mixing should be done thoroughly by inversion and swirling for at least 2 minutes.

Normal value of ESR by Westergren’s Method In male, normal value of ESR is 3–10 mm at the end of 1 hour. In female normal value of ESR is 5–12 mm at the end of 1 hour. Wintrobe’s Method In Wintrobe’s method two experiments can be done simultaneously from the same sample, i.e. ESR and haematocrit value. Apparatus Required Syringe (5 ml) with needle, Wintrobe’s tube and stand (Fig. 13.3), Pasteur pipette, i.e. dropper with long nose

Fig. 13.3: Wintrobe’s tubes and stand

Human Anatomy and Physiology:  Practical Workbook

46

• With a long-necked Pasteur pipette or transfer pipette fill the Wintrobe’s tube with this mixture up to the 0 mark (out of two graduation scale, the scale where 0 is the uppermost mark and 10 is the lowermost mark is chosen). • Start stopwatch from the moment when Wintrobe’s tube filling started. • Place the Wintrobe’s tube vertically in the Wintrobe’s stand. • Allow the tube to stand for an hour and gradu­ally at the upper part clear straw-coloured plasma appears. • Note the level up to which the red cell column has fallen down after an hour. • Enter the observation in notebook. Normal Value of ESR by Wintrobe’s Method • In male normal value of ESR is 2–8 mm at the end of 1 hour. Fig. 13.4: Wintrobe’s tube marking 10 to 0

OBSERVATION EXERCISE

• In female normal value of ESR is 4–10 mm at the end of 1 hour.

Determination of Heart Rate and Pulse Rate

14

INTRODUCTION Arterial pulse is the pressure wave pro­duced by alternate expansion and relaxation of arteries. Ejection of blood to the aorta during ventricular systole is the reason of expansion of arterial wall (Windkessel effect) and relaxation of arterial wall is occurred during ventricular diastole. Arterial pulse is transmitted along the column of flowing blood in arteries. It is not transmitted by the wall of arteries. That is why arterial pulse is absent at the distal part of obstruction point in the lumen of the artery even when the arterial walls are intact. Arterial pulse rate is equal to the heart rate except in pulse deficit. Sites for Pulse Rate Measurement a. Radial artery (Fig. 14.1) b. Carotid artery Other sites for pulse rate measurement

Fig. 14.1: Location of radial artery

a. Brachial artery b. Femoral artery c. Pedal pulse d. Temporal pulse e. Popliteal pulse

• Ask the subject for permission to assess the pulse. • Ask the subject to keep his or her hand on the working table. • Keep the wrist of the subject’s hand in semi-flexed and semi-pronated position.

Resting Pulse Rate Measurement from Radial Artery

• Palpate the pulse by placing the pad (flat part) of index finger, middle finger and ring finger on the radial artery against the lower end of radius bone (around 2 cm below the base of the thumb or proximal to the wrist joint) (Fig. 14.1).

This is the most common site to measure pulse rate. Apparatus Required Stopwatch Procedure of Resting Pulse Rate Measurement from Radial Artery

• Place all the three fingers in same line and apply very gentle pressure on the radial artery to palpate the pulse (Fig. 14.2).

• Ask subject to sit comfortably and relax for at least 5 minutes (5–10 minutes) for recording resting pulse rate.

• Count the pulse for 30 seconds and then multiply with 2 to get the pulse rate in 1 minute. 47

48

Human Anatomy and Physiology:  Practical Workbook

Normally, it cannot be felt or is just palpable. If the artery is hardened, it will feel like a cord. Resting Pulse Rate Measurement from Carotid Artery There are two (right and left) carotid arteries. The right carotid artery is located in a groove on the right side of the larynx and the left carotid artery is located in a groove on the left side of the larynx. Either artery can be used to take the carotid pulse. Apparatus Required Stopwatch Procedure of Resting Pulse Rate Measurement from Carotid Artery

Fig. 14.2: Pulse rate measurement from radial artery

Note the following characters of pulse i. Rhythm: Pulse rate reflects the cardiac rhythm. Normally, pulse is regular. When the pulse waves are repeated at regular interval in the consecutive beats then the rhythm is regular, if not, then it is irregular. Check carefully whether pulse is regular or irregular. If pulse is irregular, then very carefully examine whether it is regularly irregular or irregularly irregular. Pulse is regularly irregular in respi­ratory sinus arrhythmia. Pulse is irregularly irregular in atrial fibrillation. ii. Volume of the pulse: Volume of the pulse is a measure of pulse pressure. It is assessed by the amplitude of lift­ing of the fingers felt during pal­pa­tion. The amplitude of movement of expan­sion felt by the fingers at the time of pal­pation is due to passage of pulse wave. High pulse volume pulse is found in aortic insufficiency, thyrotoxicosis, hyper­volemia, etc. Low volume pulse is found in hypo­volemia, aortic stenosis, etc. iii. Condition of the arterial wall: Apply extra pressure on the radial artery by the thumb. Roll the radial artery against the radial bone by the examining fingers.

• Ask subject to sit comfortably and relax for at least 5 minutes (5–10 minutes) for recording resting pulse rate. • Ask the subject for permission to assess the pulse. • Palpate the carotid pulse by placing the pad (flat part) of index and middle fingers between the larynx and anterior border of sternocleidomastoid muscle of subject’s neck. • Apply very gentle pressure on the carotid artery to palpate the pulse and never assess both carotid arterial pulse simultaneously. • Count the pulse for 30 seconds and then multiply with 2 to get the pulse rate in 1 minute. Examination of Pulse Rate other than Radial Artery and Carotid Artery • The temporal pulse is felt at the temple near the ear. • The brachial pulse is felt on the inside of the elbow. • The femoral pulse is felt in the groin area (between the anterior portion of the iliac crest and the pubic tubercle). • The popliteal pulse is felt behind the knee. • The pedal pulse is felt on top of the foot in the middle of the dorsum of the foot just lateral to the tendon of extensor hallucis longus. EFFECT OF EXERCISE ON PULSE/HEART RATE Principle Moderate and severe exercise increases sympathetic discharge and decreases vagal tone. This increased sympathetic discharge causes positive chronotropic effect, positive inotropic effect, positive bathmotropic effect, possitive dromotropic effect. These positive chronotropic effect and decrease in vagal tone increase heart rate. Apparatus Required Stopwatch

Determination of Heart Rate and Pulse Rate

Procedure • Ask subject to sit comfortably and relax (mentally and physically) for 5 minutes. • Ask the subject for permission to assess the pulse. • Palpate the carotid pulse and count resting pulse rate before starting exercise. • Ask the subject to perform exercise for at least 3 minutes (either ask subject to do Harvard step test or Astride jump test for 3 minutes). • Exercise should be performed in light and comfortable clothing and after 2 hours of light breakfast. The subject should not take caffeine, nicotine, alcohol and non-essential drugs before the exercise.

49

• Immediately after stoppage of exercise and also 2 minutes, 5 minutes and 10 minutes after stoppage of exercise, palpate the carotid pulse and count for 10 seconds. • Calculate the final result (beats per minute) by multiplying with six as after exercise recording was taken for 10 seconds. • Note the recordings in tabular form. Observation Subject’s name : _____________________ Age

: _____________________

Gender

: _____________________

Observation Table Posture

Pulse/heart rate (beats per minute) palpate from carotid artery

Resting pulse rate in sitting position before starting exercise

....................................................................................................

Immediately after stoppage of exercise

....................................................................................................

After 2 minutes of stoppage of exercise

....................................................................................................

After 5 minutes of stoppage of exercise

....................................................................................................

After 10 minutes of stoppage of exercise

....................................................................................................

OBSERVATION EXERCISE

15

15 Recording of Blood Pressure

Blood pressure: The lateral pressure exerted on the wall of blood vessels by the flowing blood is known as blood pressure. Systolic blood pressure: The maximum lateral pressure exerted on the wall of blood vessels by the flowing blood during the time of systole is known as systolic blood pres­sure. It denotes the force of contraction of ventri­cle. Normal value is 110–130 mm Hg. Diastolic blood pressure: The minimum lateral pressure exerted on the wall of blood vessels by the flowing blood during the time of diastole is known as diastolic blood pres­sure. It denotes the peripheral resis­tance. Normal value is 74–84 mm Hg. Pulse pressure: It is the difference between systolic blood pressure and diastolic blood pressure. Normal pulse pressure is around 40 mm Hg. Mean pressure: It is the average pressure present throughout the cardiac cycle. It is calculated by adding one-third pulse pressure to the diastolic pressure.

palpatory method or oscillatory method or auscul­tatory method to record the blood pressure. There are three methods by which indirect blood pressure can be measured: i. Palpatory method ii. Oscillatory method iii. Auscultatory method. Apparatus Required for Measurement of Blood Pressure by Indirect Method Stethoscope (only required for auscultatory method) and sphygmo­manometer. Stethoscope It has five parts (Fig. 15.1) a. Chest piece: This part comprises two portions—one is bell-shaped part and other is the diaphragm. The

Methods of Measurement of Blood Pressure A. Direct method B. Indirect method A. Direct Method of Measurement of Blood Pressure It is an invasive technology. In this method, a cannula tube or catheter is directly inserted into the subject’s blood vessel. The catheter is then connected to a blood pressure trans­d ucer which generates an electrical signal. Nowadays, this method is used in researchbased experiment. B. Indirect Method of Measurement of Blood Pressure It is a non-invasive technology. In this method, blood flow through the brachial artery of arm (or femoral artery in leg) is occluded by inflating Riva Rocci cuff which is tied on the upper arm (or thigh). After that, the pressure is gradually released to start the blood flow through the constricted artery and the changes are studied by

Fig. 15.1: Stethoscope

50

Recording of Blood Pressure

bell-shaped part of chest piece is used for listening low-pitched sound and the diaphragm part of chest piece is used for listening high-pitched sound. b. Stem part: It is present in between the chest piece and rubber tube. A “click” sound can be heard if the stem part is rotated. By this rotation, it can be locked or unlocked and sound transmitted from the diaphragm can be blocked or unblocked. c. Rubber tube: This is a flexible single rubber tube. At the lower end it is connected to the chest piece and at the upper end connected to the ear tube. The function of this rubber tube is to transmitted the sound from chest piece to the ear tube. Few stethoscopes have double lumen tube, i.e. two sound paths inside a single ­outer tube which helps to get more clear sound especially used during cardiac exami­nation. d. Ear tubes: It is made-up of metal. It is present in between the rubber tube and ear tips. It transmits sound from the rubber tube to the ear. These ear tubes are little bit angular in structure just to fit properly in ear canal. e. Ear tips: Two separate ear tips or earpieces are attached at tip of metal ear tubes. These are made-up of plastic. These ear tips are designed in such a way that can easily and tightly fit in the external auditory canal. The ear tips provide an excellent auditory seal and comfortable fit. Sphygmomanometer It is an apparatus for determining arterial blood pressure and consists of following parts (Fig. 15.2): a. Manometer: It is a part of the sphygmomano­­meter by which the pressure in the inflatable bag, i.e.

Fig. 15.2: Sphygmomanometer

51

the external pressure exerted on the artery can be determined. It is U-shaped in structure. But one limb of this U-shaped structure is broader and shorter. The other limb of the manometer is long, narrow and graduated. The broader and shorter limb is the mercury reservoir (Fig. 15.3). b. Mercury reservoir: It is the broader and shorter limb of manometer. The upper­most part of mercury reservoir is connec­t ed with the rubber tube originating from the inflatable rubber bag of Riva Rocci cuff. One-way valve is present at the junction of the rubber tube and the upper­most part mercury reservoir. This one-way valve allows air pressure to transmit from the rubber tube of inflatable bag to the mercury column in the reservoir and also prevents the spilling of mercury when lid of sphygmomano­ meter is closed. One stopcock is present in between the mercury reservoir and the long-graduated tube. This stopcock prevents the move­ment of mercury in between the two limbs of manometer when in closed or switch-off condition. But free flow of mercury is possible when it is open or switch-on condition. c. Graduated tube: This is the long and narrow limb of manometer. The tube is graduated into 0 to 300 mm Hg. Each smallest division denotes 2 mm Hg. d. Riva Rocci cuff: It comprises a inner inflatable bag which is enclosed in non-distensible cotton fabric. Normally, the inner inflatable bag is 12–13 cm wide and 24 cm long for arm and 15–18 cm wide and 30 cm long for leg.

Fig. 15.3: Sphygmomanometer markings

52

Human Anatomy and Physiology:  Practical Workbook

  Two rubber tubes are attached with the inflatable bag of Riva Rocci cuff. The other end of one rubber tube is attached with the air pump through leak valve screw.   The other end of second tube is con­nected with the uppermost part of mercury reservoir. e. Air pump: It is designed in such way that it can easily fit in the fist of normal adult. This air pump is oval in shape. At the lower end, one-way valve is present. When this one-way valve opens, air from the external environment can enter in the air pump. It also has a leak valve screw at the upper stem part. The Riva Rocci cuff can be inflated by tightly closing the leak valve screw along with alternate squeezing and relaxation of air pump. PROCEDURE OF INDIRECT METHOD OF MEASUREMENT OF RESTING BLOOD PRESSURE i. Palpatory Method Only systolic blood pressure can be measured in this method. Diastolic pressure cannot be determined by this method. Procedure • Ask the subject to sit comfortably or lie down in the couch and relax (mentally and physically) for at least 5 minutes for recording resting blood pressure. • Ask the subject to keep his or her hand on the working table if the subject is in sitting posture or arm should be kept on the bed if subject is in lie down or supine posture. • Keep the sphygmomanometer at the heart level. If subject is in sitting posture then sphygmomanometer should be kept at the heart level and if subject is in lie down or supine posture then it should be kept in bed. • Fully open the lid of sphygmomanometer. • Switch on the stopcock of mercury reservoir. • Tie the Riva Rocci cuff around the upper arm just 2–3 cm above the antecubital fossa. The Riva Rocci cuff should not be very tight or very loose. • Palpate the pulse by placing the pad (flat part) of index finger, middle finger and ring finger on the radial artery against the lower end of radius bone (around 2 cm below the base of the thumb or proximal to the wrist joint). • Tightly close the leak valve screw. • Alternately, squeeze and relax the air pump to inflate the cuff. • Raise the mercury column slowly up to 150 to 160 mm Hg (at least 40 mm Hg above the point when pulse disappeared). • Then, open the leak valve screw in such a way that mercury column will fall at a rate of 2–3 mm Hg at each time.

• Record the pressure at which point pulse again reappeared for the first time. • The height of the mercury in graduated mano­­­meter at this moment denotes the systolic blood pressure. • Enter the observation in notebook. ii. Auscultatory Method This is the most convenient and reliable method out of three methods. Systolic and diastolic pressures both can be measured in this method and is generally used in daily practice. Procedure • Ask the subject to sit comfortably or lie down in the couch and relax (mentally and physically) for at least 5 minutes for recording resting blood pressure. • Ask the subject to keep his or her hand on the working table if the subject is in sitting posture or arm should be kept on the bed if subject is in lie down or supine posture. • Keep the sphygmomanometer at the heart level. If subject is in sitting posture then sphygmomanometer should be kept at the heart level and if subject is in lie down or supine posture, then it should be kept in bed. • Fully open the lid of sphygmomanometer. • Switch on the stopcock of mercury reservoir. • Tie the Riva Rocci cuff around the upper arm just 2–3 cm above the antecubital fossa. The Riva Rocci cuff should not be very tight or very loose. • Locate the place at antecubital fossa where brachial artery bifurcated into radial and ulnar artery. This place is just medial to the tendon of the bicep at antecubital fossa. • Hold the chest piece of the stethoscope with the help of index, middle and ring fingers of your dominant hand. • Place the chest piece of the stethoscope with three fingers at that particular area and place the thumb at posterior part of the cubital fossa. • Tightly close the leak valve screw. • Alternately, squeeze and relax the air pump to inflate the cuff. • Raise the mercury column slowly up to 150 to 160 mm Hg (at least 40 mm Hg above the point of systolic blood pressure deter­mined by palpatory method). • Then, open the leak valve screw in such a way that mercury column will fall at a rate of 2–3 mm Hg at each time. • Record the mercury column or pressure at which point the first sharp, clear, tapping sound appeared. This pressure denotes the systolic blood pressure. At a point where pressure in the cuff just balances the arterial pressure (or arterial pressure just overcomes pressure in cuff), an intermittent flow of

Recording of Blood Pressure

53

blood begins in the narrow artery distal to the cuff producing a sharp light and tapping sound which is audible by stethoscope. This pressure is the systolic blood pressure. • As the mercury column reduced this sound changes its intensity and quality and can be divided into 5 phases (Korotokoff sounds), i.e. 1. Clear tapping sound or phase I: It is first heard at systolic blood pressure point and it is continued for 10–12 mm Hg when the pressure gradually lowered. 2. Murmurish sound or phase II: For next 10–15 mm Hg, the sound becomes changed into murmurish sound. 3. Loud banging sound or phase III: In the next phase, sound is much louder, clear and knocking or banging like sounds auscultated. It is continued for next 10–14 mm Hg. 4. Muffled sound or phase IV: Suddenly, the sound becomes muffled and it is continued for next 5–6 mm Hg. 5. Disappearance of sound or phase V: After phase IV, sound finally disappears. • Record the mercury column or pressure at which point sound completely disappears. This pressure indicates diastolic pressure. • Some people prefer to note the diastolic pressure at the point where sudden muffling of sound appears (stage IV) rather than when it completely disappears. • Enter the observation in notebook.

• Raise the mercury column slowly up to 150 to 160 mm Hg (at least 40 mm Hg above the point of systolic blood pressure determined by palpatory method). • Then, open the leak valve screw in such a way that mercury column will fall at a rate of 2–3 mm Hg at each time. • Record the mercury column or pressure at which point the first oscillation in the mercury column is observed. This pressure denotes the systolic blood pressure. • Record the mercury column or pressure at which point oscillation in the mercury column is completely disappears. This pressure denotes the diastolic blood pressure. • Enter the observations in notebook.

iii. Oscillatory Method

Effect of Posture on Blood Pressure

Procedure

Principle

• Ask the subject to sit comfortably or lie down in the couch and relax (mentally and physically) for at least 5 minutes for recording resting blood pressure. • Ask the subject to keep his or her hand on the working table if the subject is in sitting posture or arm should be kept on the bed if subject is in lie down or supine posture. • Keep the sphygmomanometer at the heart level. If subject is in sitting posture then sphygmomanometer should be kept at the heart level and if subject is in lie down or supine posture then it should be kept in bed. • Fully open the lid of sphygmomanometer. • Switch on the stopcock of mercury reservoir. • Tie the Riva Rocci cuff around the upper arm just 2–3 cm above the antecubital fossa. The Riva Rocci cuff should not be very tight or very loose. • Tightly close the leak valve screw. • Alternately, squeeze and relax the air pump to inflate the cuff.

Measurement of effect of posture is very useful method to evaluate cardiovascular regulatory mechanisms. Change in posture from supine to standing results in pooling of blood in lower extremities of the body due to gravitational force. This causes decrease in venous return, stroke volume and eventually cardiac output. Decrease in cardiac output leading to immediate and transient reduction in blood pressure. This sudden fall in blood pressure can be measured immediately after the postural change. Fall in blood pressure sensed by high pressure baro-receptor system. Baro-receptor response causes positive chronotropic effect, positive inotropic effect, positive bathmotropic effect, positive dromotropic effect and vasoconstriction and increase in diastolic blood pressure within 10–15 seconds. Failure of this correction (as in autonomic neuropathy) leads to postural hypotension defined as systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg sustained for 3 minutes or longer.

Recording of Blood Pressure in Different Arms Procedure Record blood pressure in different arms. Observation Subject’s name Age Gender

: _____________________ : _____________________ : _____________________

Arm

Blood pressure Systolic blood pressure (mm of Hg)

Left arm

Diastolic blood pressure (mm of Hg)

.........................

.........................

Right arm .........................

.........................

Human Anatomy and Physiology:  Practical Workbook

54

Apparatus Required

Effect of Exercise on Blood Pressure

Sphygmomanometer, stethoscope and couch.

Principle

Procedure • Ask the subject to lie on bed or couch for 5 minutes and record resting blood pressure in supine position (lie down). • Disconnect the rubber tube of Riva Rocci cuff from sphygmomanometer and keep the Riva Rocci cuff tied as it was around the upper arm. • Place the sphygmomanometer at around 4 and half feet height table (sphygmomanometer should be kept at the chest level of the subject). • Ask the subject to stand up and remain standing. Ensure the subject is in relaxed condition and with minimum effort. • Record the blood pressure in standing position immediately after standing from supine position and at 2 minutes and 5 minutes after standing. • Note the recordings in tabular form. Observation Subject’s name Age Gender

: _____________________ : _____________________ : _____________________

Observation Table Posture

Blood pressure (BP) Systolic BP (mm of Hg)

Diastolic BP (mm of Hg)

Supine position

......................... .........................

Immediate standing

......................... .........................

After 2 minutes of standing ......................... ......................... After 5 minutes of standing ......................... .........................

Moderate and severe exercise increases sympa­thetic discharge. This increased sympathetic discharge causes positive chronotropic effect, positive inotropic effect, positive bathmotropic effect, positive dromotropic effect and vasoconstriction. This causes increase in stroke volume and cardiac output. These changes initially increase both systolic and diastolic blood pressures. Apparatus Required Sphygmomanometer, stethoscope and stopwatch. Procedure • Ask the subject to sit comfortably and relax (mentally and physically) for 5 minutes and then after 5 minutes record resting blood pressure in sitting position before starting exercise. • Disconnect the rubber tube of Riva Rocci cuff from sphygmomanometer and keep the Riva Rocci cuff tied as it was around the upper arm. • Ask the subject to perform exercise for at least three minutes (either ask subject to do Harvard step test or Astride jump test for 3 minutes). • Exercise should be performed in light and comfortable clothing and after 2 hours of light breakfast. The subject should not take caffeine, nicotine, alcohol and non-essential drugs before the exercise. • Record the blood pressure immediately after stop­ page of exercise and also 2 minutes, 5 minutes and 10 minutes after stoppage of exercise. • Note the recordings in tabular form. Observation Subject’s name Age Gender

: _____________________ : _____________________ : _____________________

Observation Table Exercise

Blood pressure Systolic blood pressure (mm of Hg)

Diastolic blood pressure (mm of Hg)

Immediate after stoppage of exercise

........................................

.................................. ......

After 2 minutes of stoppage of exercise

........................................

.................................. ......

After 5 minutes of stoppage of exercise

........................................

.................................. ......

After 10 minutes of stoppage of exercise

........................................

.................................. ......

Semester II

Integumentary and Special Senses STUDY OF INTEGUMENTARY AND SPECIAL SENSES

Label the various parts in the following figures:

Fig. 1.1:  Histology of thin skin with nerve endings

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Fig. 1.2:  Histology of thick skin

A

B Figs 1.3A and B:  Tongue: A. Gross anatomy; B. zones of different tastes on tongue

Integumentary and Special Senses

Fig. 1.4A:  Types of papillae with taste buds

Fig. 1.4B:  Magnified taste bud

Fig. 1.5A:  Olfactory rootlets for sense of smell

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Fig. 1.5B: Histology of olfactory epithelium

Fig. 1.6:  Visual pathway

Integumentary and Special Senses

Fig. 1.7: Cross-section of human eye

Fig. 1.8: Membranous labyrinth

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Fig. 1.9: Structure of cochlea

Nervous System STUDY OF NERVOUS SYSTEM

Label the various parts in the following figures:

Fig. 2.1: Structure of neuron

Fig. 2.2A: Synapse: Low power magnification

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2

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Fig. 2.2B: High power magnification

Fig. 2.3: Ventricles of brain

Nervous System

Fig. 2.4: Spinal cord with 31 pairs of spinal nerves

Fig. 2.5: Location of descending tracts in spinal cord

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Fig. 2.6: Location of ascending tracts in spinal cord

Fig. 2.7: Blood supply of spinal cord

Nervous System

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Fig. 2.8: Attachment of cranial nerves to the ventral surface of brainstem with external features of medulla oblongata, pons and midbrain

Fig. 2.9: Sulci and gyri on superolateral surface of left cerebral hemisphere

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Fig. 2.10: Parts of the thalamus. The afferents to the nuclei of thalamus are also indicated

Fig. 2.11: Boundaries and parts of internal capsule

Nervous System

Fig. 2.12: Circle of Willis and the branches of arteries supplying the brain

Fig. 2.13: Arterial supply of superolateral surface of right cere­bral hemisphere

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Fig. 2.14: Arterial supply of medial surface of right cerebral hemisphere

Fig. 2.15: Arterial supply of inferior surface of cerebral hemisphere

Endocrine System STUDY OF ENDOCRINE SYSTEM

Label the various parts in the following figures:

Fig. 3.1: Endocrine glands

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3

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Fig. 3.2: Pituitary gland: Anatomy

Fig. 3.3: Thyroid gland—location and parts

Endocrine System

A

B

Figs 3.4A and B: Adrenal gland: A. Location; B. cut section

Fig. 3.5A: Anatomy of pancreas with pancreatic islet

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Fig. 3.5B: Cells of the islets of Langerhans

STUDY OF HORMONAL PROBLEMS Identify the hormonal problems in the following pictures and write their names in the blank spaces.

Fig. 3.6: _______________________________________________________

Endocrine System

Fig. 3.7: _______________________________________________________

Fig. 3.8: _______________________________________________________

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Fig. 3.9: _______________________________________________________

Fig. 3.10: _______________________________________________________

Demonstration of General Neurological Examination and Cranial Nerves

4

• Repetition – “Repeat after me: I went to the store and forgot my wallet”. • Naming – Point to objects around room, asking what they are: Watch, pen, telephone. – If done well, ask more difficult ones: (Watch) Band, (pen) cap, (telephone) receiver. • Reading – Have subject read and follow a written command: Close your eyes. • Writing – Have the subject write a complete sentence of his/ her choice.

I. MENTAL STATUS A. Level of Consciousness • Note if awake and alert. • If not, describe what level of stimulation is needed to arouse and keep the subject awake. For example: “Opens eyes to noxious stimuli; falls back asleep if not continuously stimulated”. B. Attentiveness • The subject is attentive if able to attend to you and to the examination without getting easily distracted. • Have the subject spell WORLD backwards or count backwards or say the months of the year backwards. C. Orientation

E. Memory

• Ask the subject his/her full name, location, and full date. • Subject is ‘oriented × 3, if all the 3 are entirely correct. • If not ‘oriented × 3’, write out subject’s responses. Do not say ‘oriented × 2 (or 1)’.

• Registration: “Repeat these words after me: Apple, table, and penny”. • “ Do not proceed to memory testing until subject says them all correctly”. • Immediate recall: 1–3 minutes later, “What were those 3 words I asked you to remember”? • Recent memory: “What did you have for breakfast this morning”? • Remote memory: “Where did you grow up/go to school? When was your wedding/child born/military service”?

D. Speech and Language Listen to subject’s verbal output: Motor ability to produce words, quantity of spontaneous speech, rate of speech production, sentence structure, accuracy/ appropriateness of words used, and ability to repeat a sentence, follow commands, and come up with the right words for things. • Fluency is normal if subject speaks in complete sentences without hesitancy between words. • Comprehension is normal if subject is able to answer your questions appropriately and follow exam instructions. – “Do what I say: Look to the door and then look to the window”.

F. Higher Intellectual Function • General knowledge: “Who is the president of India /Prime minister of India? What is the capital of Uttar Pradesh, India”? • Abstraction: “What does ‘People in glass houses shouldn’t throw stones’ mean?” • Judgment: “What would you do if you found a sealed, stamped, addressed envelope lying on the ground?” • Insight: “Why did your daughter bring you to the hospital?” • Reasoning: “How do a lie and a mistake differ?”

– If not done perfectly, give simpler command: “Show me your thumb”.

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Fig. 4.1: Attachment of cranial nerves to the base of brain

II. CRANIAL NERVES

– Wiggle a finger of one hand.

A. Cranial Nerve I: Olfactory

– Ask the subject to indicate on which side the finger is moving.

• Have the subject close his/her eyes. • Occlude one nostril and test other using non-irritating substances (e.g. vanilla, cloves, coffee). Avoid those that stimulate trigeminal nerve endings or taste buds (e.g. peppermint, menthol, ammonia, alcohol swabs). • Compare both the sides. B. Cranial Nerve II: Optic • Visual acuity – Hold Snellen chart at comfortable reading distance (about 14 inches). – Cover 1 eye and have the subject read chart. – For each eye, record the smallest line that the subject can read. – Glasses should be left on (looking for optic nerve lesion, not refractive error). • Visual fields – Stand just in front of the subject and have subject look you in both eyes. – Hold your hands midway between you and the subject far enough laterally that you can barely see them out of the corner of your eyes.

– Repeat in upper and lower temporal quadrants. – If abnormality is suspected or is found on screening test above, test all 4 quadrants of each eye individually. ™ Have the subject close one eye; you should close your own eye that is opposite the subject’s closed eye, since you will be serving as the normal control. ™ Move a finger or penlight into the periphery of each visual quadrant (upper and lower temporal and nasal), asking the subject to indicate when movement is detected. It should be seen by you and the subject at the same time. • Fundoscopy – Have the subject focus on a distant wall. – Be sure your head is not obstructing the subject’s view of that target. – View optic disc using ophthalmoscope. – Note the disc color and the presence of venous pulsations, papilledema (disc hyperemia, blurred margins, absent venous pulsation), or hemorrhages.

Demonstration of General Neurological Examination and Cranial Nerves

• Pupillary function (CN II and CN III) a. Test pupillary reaction to light – Dim room lights as necessary. – Ask the subject to look into distance to avoid effect of accommodation. – Shine bright light obliquely into each pupil. – Look for both direct (same eye) and consensual (other eye) constriction. – Record pupil size in mm (normal is about 2–5 mm) and any asymmetry or irregularity. b. If light reflex is abnormal, test pupillary reaction to accommodation. – Hold finger 10 cm from the subject’s nose. – Have the subject alternate looking into distance and at finger. – Observe pupillary response. C. Cranial Nerves III, IV and VI: Oculomotor, Trochlear and Abducens • Visual inspection – Look at ocular alignment at rest (primary gaze). Does the reflection of light hit at same location in each eye? Is one eye deviated in, down and out, or up? – Observe for ptosis (lid droopiness). • 6 cardinal directions of gaze – Stand at 3–6 feet in front of the subject. – Ask the subject to follow your finger with the eyes without moving the head. Place your hand on top of head to keep it still if necessary. – Move your finger in the six cardinal directions and observe whether movements are full in each eye. • Convergence – Ask the subject to follow your finger with the eyes without moving the head. Hold lids up if necessary. – Move your finger toward bridge of subject's nose and observe eye movements. • Smooth pursuits (smooth following movements) – Steadily move your finger horizontally and then vertically as in testing individual extraocular muscles, but this time, look at the smoothness of following movements. • Saccades (discrete, rapid movements from one object to another) – Hold up your hands in front of the subject (with each hand held a few inches lateral to the eye). – Have the subject alternate looking from one hand to the other. – Observe accuracy with which eyes reach target. Do he/she consistently undershoot or overshoot the target? Is there oscillation before hitting the target?

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• Nystagmus – Observe for involuntary horizontal, vertical, or rotary oscillation of the eyeballs at primary gaze (looking straight ahead) and on sustained hori­ zontal and vertical gaze. – If present, note direction of movement and whether movement persists or fatigues. • Pupillary light response (see CN II) D. Cranial Nerve V: Trigeminal • Facial sensation – Explain to subject what you intend to do. – Use sharp end of a broken cotton swab or a pin to test pain sensation on forehead, cheek, and jaw of each side of face. – Ask the subject to tell you whether he/she feels about the same on both sides. – If not, map out where abnormality is to see if it conforms to distribution of trigeminal nerve. Specifically, march stimulus from forehead back past hairline, from cheek to tragus of the ear, and from jaw to neck. (V1 extends far back to the top of the skull—it does not end at the hairline. V3 ends just above the jaw line inferiorly and just before the ear laterally.) • Corneal reflex (CN V and CN VII) – Lightly touch peripheral aspect of cornea from the side with fine wisp of cotton. – Look for normal blink reaction of both the eyes. – Repeat on other side. – If response is less than brisk, touch cornea more centrally. • Temporalis and masseter strength. – Ask the subject to open mouth and clench teeth. – Palpate temporalis and masseter muscles. E. Cranial Nerve VII: Facial • Observe for any facial asymmetry at rest in forehead wrinkles, palpebral fissure width, nasolabial folds, or corner of mouth. • Ask the subject to do the following and note any lag, weakness, or asymmetry: – Smile – Puff out cheeks – Close both the lips and resist your attempt to open them. – Close both the eyes and resist your attempt to open them. – Raise eyebrows • Corneal reflex (see CN V)

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F. Cranial Nerve VIII: Acoustic • Screen hearing – Face the subject and hold your arms with your fingers near each ear. – Rub your fingers together on one side. – Ask subject to tell you when and on which side the rubbing is. – Increase intensity as needed. – Note any asymmetry. G. Cranial Nerves IX and X: Glossopharyngeal and Vagus • Listen the subject’s voice. Note any hoarseness, nasal, or breathy quality. • Ask the subject to say ‘Ah’ and watch movement of soft palate and pharynx. (Do not pay attention to uvula, which can deviate to one side or another in the normal person.) – Note any asymmetry of palate elevation. • Ask the subject to swallow and to cough. • In the unconscious or uncooperative subject, test gag reflex. – Stimulate back of throat with a cotton swab on each side. – Look for gagging after each stimulus. H. Cranial Nerve XI: Spinal Accessory • Trapezius. – From behind the subject, look for atrophy or asymmetry of trapezii. – Ask the subject to shrug shoulders against resistance and note strength. – Ask the subject to push head back against resistance and note strength. • Sternocleidomastoid. – Place hand on lower face and ask the subject to turn head towards that side against resistance. – Observe contraction of opposite sternocleido­ mastoid I. Cranial Nerve XII: Hypoglossal • Note tongue position at rest in the mouth and on protrusion. Does tongue deviate in either position? • Ask the subject to stick out tongue and move it from side to side. Note strength and rapidity of movements. • Have the subject push tongue into each cheek while you push from the outside. Note strength. III. SENSORY SYSTEM • General points 1. Explain each test before you do it. 2. Unless otherwise specified, the subject's eyes should be closed during testing.



3. Test all 4 extremities. 4. Compare side-to-side and ask if the two sides are about the same. Avoid leading questions like ‘Is this sharp’? 5. Compare distal and proximal areas of the extremities. 6. When you detect an area of sensory loss, map out its boundaries in detail. • Vibration – Use a 128-Hz (low-pitched) tuning fork. – Lightly strike tines against your hand and place the stem of the fork over the most distal joint of the subject's great toe. – Ask whether the subject feels anything and what the sensation is. – If vibration is felt, ask when it goes away. Count the number of seconds. – Repeat on the other side, being sure to strike the fork with about equal force, and compare the duration of vibration. – If the vibration sense is impaired, move proximally one joint at a time until it is felt. Test the fingers in a similar fashion. • Joint position sense – Grasp the subject's great toe on the sides of the distal phalanx and hold it away from other toes to avoid friction. – Demonstrate to the subject what ‘up’ and ‘down’ feel like and tell the subject you will move the toe in one of these two directions only. – Move the toe a few degrees and ask the subject to identify the direction in which the toe was moved. – If position sense is impaired, increase stimulus intensity (move the toe a greater distance); if still impaired, test at a more proximal joint (ankleknee-hip). – Test the fingers in a similar fashion. • Pain – Use a safety pin or sharp end of a broken cotton swab. – Test for a distal gradient of sensory loss in the leg by applying stimulus at the toes and marching your way up to the knee. ™ Ask the subject if the sensation is ‘about the same’ or if it changes as you move up the leg. – Test for sensory loss in the most commonly affected nerve and nerve root distributions. a. Test the following areas: – Palmar aspect of the index finger (median nerve) – Palmar aspect of the 5th finger (ulnar nerve) – Web space between thumb and index finger on dorsal surface of the hand (radial nerve)

Demonstration of General Neurological Examination and Cranial Nerves

– Web space between the great toe and a 2nd toe on the dorsal surface of the foot (L5) – Lateral surface of the foot (S1) b. Apply stimulus to one and then another of these locations in the upper or lower extremity, asking the subject if the two areas are ‘about the same’. – If the subject complaining of sensory symptoms, move stimulus from abnormal area to normal area, asking the subject to report when stimulus begins to feel stronger. ™ Another technique is to apply stimulus to an uninvolved part of the body and then apply stimulus to the involved part. • Temperature – Testing of temperature is usually reserved for the subject in whom testing of pain sensation is abnormal. – Press a cold tuning fork against the skin to make sure there is temperature loss in the same distribution as pain loss. • Light touch – Touch the skin lightly with your fingers. – Ask the subject to respond whenever a touch is felt (e.g. ‘left arm’). – Test face, arms, and legs in random order. IV. MOTOR SYSTEM • Visual inspection – Note muscle bulk. Look for generalized or focal muscle wasting or hypertrophy. – Look for extraneous movements, e.g. tremor (at rest? with action?), fasciculation (muscle twitching). – Note speed of movement, e.g. slow to initiate (bradykinesia). • Tone (muscle tension at rest) – Ask the subject to relax. – Flex and extend subject’s wrists, elbows, ankles, and knees. – Look for resistance that is decreased (hypotonia) or increased (throughout range of motion = rigi­ dity; spring-like = spasticity). • Strength and endurance – Isolate muscle you are testing, so the subject cannot use strong muscles that have similar function to compensate for weak one being tested. – Fix proximal joint when testing distally, e.g. if testing pronation, fix the humerus, so the subject

79

cannot use shoulder to compensate for weak pronation. – Give yourself the advantage, e.g. when testing deltoid, press on outstretched hand rather than on elbow. – Have the subject walk on heels and toes and do deep knee bend or get out of chair without using arms. – Test at least the following muscles on both sides: ™ Deltoid: Abduction (elevation) of upper arm (C5–C6; axillary nerve). ™ Biceps: Flexion of forearm at elbow (C5–C6; musculocutaneous nerve). ™ Triceps: Extension of forearm at elbow (C6–C8; radial nerve). ™ Extensor carpi radialis: Dorsiflexion of hand at wrist (C5–C6; radial nerve). ™ Abductor pollicis brevis: Palmar abduction of thumb with thumb at right angle to palm (C8– T1; median nerve). ™ Interossei: Finger abduction (dorsal) and adduction (palmar) (C8–T1; ulnar nerve) ™ Iliopsoas: Hip flexion (L1–L3; femoral nerve). ™ Quadriceps: Knee extension (L2–L4; femoral nerve). ™ Hamstrings: Knee flexion (L5–S2; sciatic nerve). ™ Tibialis anterior: Foot dorsiflexion (L4–L5; deep peroneal nerve). ™ Gastrocnemius/soleus: Foot plantar flexion (S1–S2; tibial nerve). – Assign score of 0–5 for each muscle based on Medical Research Council scale. Grade

Description

0/5

No muscular contraction

1/5

Visible muscle contraction, but no movement at the joint

2/5

Movement at the joint, but not against gravity

3/5

Movement against gravity, but not against added resistance

4/5

Movement against resistance, but less than full

5/5

Movement against full resistance; normal strength

IV. REFLEX ACTIVITY Reflex activity discussed in separate chapter (i.e. Demon­ stration of reflex activity).

5

Demonstration of the Function of Olfactory Nerve • Request that the participant smell each of the test items through a different nostril. • Use +/– sign in the observation table to record the result for various odorant’s smell perception. • Repeat the smell perception tests for peppermint and other odorants for the left nostril and record the results in the observation table.

PRINCIPLE Smell perception and adaption are controlled by the olfactory nerve (cranial nerve I). The process through which smell is perceived is outlined below: • The olfactory impulse is transmitted through the olfactory nerve to the olfactory bulb in the frontal cerebral cortex. • The olfactory receptors are located in the nasal epithe­ lium in the superior section of the nasal cavity and are activated by various odorant stimuli. • The impulse is carried by the olfactory bulb neurons along the olfactory tract to the limbic system, thalamus, and primary olfactory area of the temporal cortex. The olfactory receptors sensitivity to an odor dimi­ nishes during continual stimulation. Generally, a minute after being exposed to the odorant stimuli, total insensitivity to specific odors takes place. It follows a similar olfactory pathway to that previously mentioned.

b. Procedure of Demonstration of Smell Adaptation • Ask the subject to sit comfortably and relax with both the eyes closed. • Ask the subject to close his or her left nostril by squeezing. • Place several drops of peppermint oil (or any other substance, e.g. clove oil, alcohol, turpentine oil, etc. with a strong, distinct odor) on a cotton swab. • Hold the cotton swab under the subject’s open right nostril (Fig. 5.1).

APPARATUS REQUIRED Peppermint oil, clove oil, alcohol, turpentine oil, etc. PROCEDURE a. Procedure of Demonstration of Smell Perception • Ask the subject to sit comfortably and relax with both the eyes closed. • Ask the subject to close his or her left nostril by squeezing. • Place several drops of peppermint oil (or any other substance, e.g. clove oil, alcohol, turpentine oil, etc. with a strong, distinct odor) on a cotton swab. • Hold the cotton swab under the subject’s open right nostril (Fig.5.1). • Ask the subject to inhale normally through his or her right nose in order to identify them but exhale through mouth.

Fig. 5.1: Demonstration of the function of olfactory nerve

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Demonstration of the Function of Olfactory Nerve

• Ask the subject to inhale normally through his or her right nose and ask the subject to inform you immediately when the smell of peppermint oil (or particular odorant which is used for the test) is significantly diminished or disappears. • Olfactory adaptation will occur when the odor is significantly diminished or disappears. • Record the time duration starting from holding the cotton swab under subject’s nostril to the moment when adaptation completed and note the duration in the observation table. • Repeat the smell adaptation tests for peppermint and other odorants for the left nostril and record the results in the observation table. OBSERVATION Subject’s name Age Gender

: _____________________ : _____________________ : _____________________

OBSERVATION EXERCISE

81

Observation Table for Smell Perception Test

Smell perception result

Peppermint oil

Clove Alcohol oil

Turpentine oil

Right nostril Left nostril

Observation Table for Smell Adaptation Test

Duration of smell Peppermint adaptation (sec) oil Right nostril Left nostril

Clove Alcohol oil

Turpentine oil

6

Examination of the Different Types of Taste • The impulses from the tongue are conducted to medulla oblongata and projects to limbic system, hypothalamus and thalamus.

PRINCIPLE Sweet, sour, salty, and bitter are the four basic taste sensations. These sensations are perceived by taste receptors, also known as gustatory receptors. These are found in taste buds in various parts of the tongue. On the tongue, the sweet taste is closest to the tip, followed by salt on the sides and top, bitterness in the back, and a sour taste in the middle (Fig.6.1). The process through which taste sensation is perceived is outlined below: • When food dissolves in saliva, chemical impulses from the food activate gastrointestinal receptors. • The impulse is carried by the facial nerve (VII cranial nerve), which originates from the anterior two-thirds of the tongue, the glossopharyngeal nerve (IX cranial nerve), which originates from the posterior one-third of the tongue, and the vagus nerve (X cranial nerve), which originates from the throat and epiglottis.

• The nerve fibers from the thalamus extend to primary gustatory area in parietal cerebral cortex and helps in perception of taste. APPARATUS REQUIRED Strong solution of sugar (10% sucrose solution) for sweet taste, strong solution of common salt (20% sodium chloride solution) for salty taste, weak solution of citric acid (1–2% citric acid solution) for sour taste, weak solution of quinine (0.1–0.2% quinine solution) for bitter taste, droppers, dry gauze, four paper board where sweet, salt, sour or bitter is written in each board with a sketch pen. PROCEDURE • Ask the subject to sit comfortably and relax with both eyes closed. • Ask the subject to protrude his or her tongue. • Ask the subject to rinse the mouth with water for 3–5 times and dry it with the help of dry gauze. • Pour few drops of sugar solution with the help of a dropper at the tip of the tongue. • Ask the subject to indicate the taste experienced by him or her by pointing with his or her finger towards the specific paper board (where sweet, salt, sour and bitter is written in each board with sketch pen). • The tongue should be kept out and not withdrawn to avoid the spreading of the test substance. • Repeat the procedure with all other three types of solutions by applying them one by one in the same manner after rinsing the mouth 3 to 5 times, on the sides near the tip, the anterior two-thirds, and the posterior one-third of the tongue.

Fig. 6.1: Various types of taste sensation in different parts of the tongue

82

Examination of the Different Types of Taste

• Record whether the perception of taste by him or her is correct or not, and also grade the intensity of taste sensation as per the following scale: Intense (+ + +), moderate (+ +), mild (+), or completely absent (-).

83

OBSERVATION Subject’s name Age Gender

: _____________________ : _____________________ : _____________________

Observation Table for Taste Test Different solutions

Taste perception

Intensity of taste perception Intense

Strong solution of sugar (10% sucrose solution) for sweet taste Strong solution of common salt (20% sodium chloride solution) for salty taste Weak solution of citric acid (1–2% citric acid solution) for sour taste Weak solution of quinine (0.1–0.2% quinine solution) for bitter taste

OBSERVATION EXERCISE

Moderate

Mild

Completely absent

7

Demonstration of the Visual Acuity

PRINCIPLE The ability of the eye to detect object details and to distinguish shapes at a specific distance is measured by visual acuity (VA). Visual acuity is defined as the minimum separable distance between two adjacent points or lines. To identify any changes in vision, it is critical to test VA in a regular manner. Each eye should be examined separately. It is measured by using standard charts containing letters of different sizes or containing symbols of different sizes. These charts are kept at a specific distance and the subject is asked to read or explain the orientation of different letters or symbols. Visual acuity is recorded according to the formula: VA = d/ D VA = visual acuity D = The distance at which the letter is read by the subject

Fig. 7.1A: Snellen’s chart

D = The distance at which it should be read by person having normal vision and the distance for normal vision is written above row of letter or symbols. Requirements Snellen’s Chart or E Chart and Jeager’s Chart Snellen’s Chart: The chart has printed letters or symbols of varying sizes and arranged in eight lines (Figs 7.1A and B). The top letter on the Snellen’s chart is visible at a distance of 60 metres by a subject having normal vision and subsequently smaller letter lines are visible from a distances of 36, 24, 18, 12, 9, 6 and 5 metres. The subject stand or sit at a distance of 6 metres or 20 feet away from the chart is believed to be an optical distance of 60 metres while the ciliary muscles are completely at relaxed position. Visual acuity is read as 6/60, 6/36, 6/24, 6/18, 6/12, 6/9 and 6/6 and the normal person’s vision is VA = 6/6. The lowest line which subject can read determines the distant vision acuity.

Fig. 7.1B: Snellen’s chart

84

Demonstration of the Visual Acuity

85

Fig. 7.2A: Jeager’s chart

Fig. 7.2B: Jeager’s chart

Jeager’s Chart: The Jeager’s chart consists of letters or paragraphs of various sizes in different languages increasing from 23 mm to 25 mm (Figs 7.2A and B). The chart is based on printed point system. The smallest print used is N5 and the largest point is N36. As you progress to larger point, the lettering size increases for lesser visual acuity. Persons with normal vision should be able to read the smallest print in well illuminated condition at a comfortable reading distance. The card is placed at 14 inches from the subject’s eye for the test. The size of the print read by the subject determines the near vision acuity.

• Then place the Jeager’s chart at 14 inches from the subject’s eye and it should be ensured that chart is well illuminated. • After that ask the subject to gently cover one eye with his/her palm. • Then ask the subject to read loudly from the topmost line of the chart and then subsequently the downward lines. • Note the smallest line which can be read clearly and effortlessly by the subject. • The near visual acuity recorded by the letter N followed by a number indicating the size of the letter (5, 6, 8, 10, 12, 14, 18, 24, 36, and 48). • Express the result as J1, J2, etc. J1 is equivalent to N5 and indicates normal near vision. • Examine each eye separately and note the result in observation table.

PROCEDURE a. Distant Vision • Chart should be hanged on the wall before starting the experiment. • It should be ensured that adequate natural light or illumination on the chart is available. • Ask the subject to stand or sit at a distance of 6 meters or 20 feet from the Snellen’s chart. • Ask the subject to remove spectacles or contact lens if already has worn. • Ask the subject to gently cover one eye with his or her palm. • Then ask the subject to read the line from the top of the chart and also from left side to right side. • Note the lowest line which subject can read correctly and effortlessly. • Examine each eye separately and note the result in observation table. b. Near Vision • Ask the subject to sit comfortably. • Ask the subject to remove spectacles or contact lens if already has worn.

OBSERVATION Subject’s name Age Gender

: _____________________ : _____________________ : _____________________

a. Distant Vision Visual Acuity Right Eye Left Eye

b. Near Vision Visual Acuity Right Eye Left Eye

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OBSERVATION EXERCISE

Human Anatomy and Physiology:  Practical Workbook

Demonstration of Reflex Activity Reflex is an automatic, involuntary contraction of muscles or group of muscles to an adequate stimulus. Reflex arc is the basic unit of integrated reflex activity consists of a sense organ, an afferent neuron, one or more synapses within a central integrating station, an efferent neuron, and an effector organ. Reflex arc may be monosynaptic or polysynaptic. If the reflex arc involves only one synapse between the afferent and efferent neurons it is called monosynaptic reflex (e.g. stretch reflex). But when reflex arc comprised with one or more inter-neurons are called polysynaptic reflexes (e.g. withdrawal reflex). Deep reflexes are produced by stretching of a muscle. When the tendon of a slightly stretched muscle is struck sharply, there is reflex contraction of that particular muscle occurs for a brief time period. A monosynaptic reflex, stretch reflex, provides information about the motor as well as the sensory system. Absence of a stretch reflex more commonly indicates sensory rather than motor disease. Superficial reflexes are induced by stimulations of receptor present in the skin or mucous membrane. These reflexes are polysynaptic reflexes. Disease of sensory fibers or posterior nerve root, lesions in grey matter and motor fibers and muscles affect the superficial reflexes.

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• Then locate the patellar tendon and strike the patellar tendon with the broad end of reflex hammer. • The strike delivery should be sharp enough. • Observe the contraction of the quadriceps femoris muscle and it will be leading to extension of the knee (Fig. 8.1). • Repeat the procedure on the other leg. • Record the response. Ankle Jerk or Reflex • Ask the subject to lie down comfortably on the examination couch. • Ask the subject to place his/her leg in slightly flexed and everted position. • Then with your nondominat hand slightly dorsiflex the foot to stretch it. • Strike over the posterior aspect of the Achilles tendon (tendon of gastrocnemius muscle) with the broad end of the reflex hammer. • Observe the contraction of the calf muscle which will be leading to plantar flexion at the ankle joint (Fig. 8.2).

REQUIREMENTS Reflex hammer, key, cotton and examination couch. Grading of reflexes: Grade 0: Absent of reflex Grade 1: Present and normal Grade 2: Faster than normal Grade 3: Very fast and quick than normal Grade 4: Clonus DEEP REFLEXES Knee Jerk or Reflex • Ask the subject to sit comfortably with freely hanging his/her leg over the other knee or ask the subject to sit at the edge of the bed.

Fig. 8.1: Elicitation of a knee jerk

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Triceps Jerk or Reflex • Ask the subject to sit comfortably or lie down comfor­ tably on the examination couch. • Ask the subject to flex his or her elbow at 90° angle. • Support the subject’s arm with your non-dominant if he/she in sitting position or allow the forearm to keep over his/her lower part of the chest if he/she is in lie down position. • Strike above the subject’s triceps tendon just above the olecranon with the narrow end of the reflex hammer by delivering a sharp stroke. • Observe the contraction of the triceps muscle (Fig. 8.4). • Repeat the procedure on the other hand. • Record the response. Fig. 8.2: Elicitation of the ankle jerk

• Repeat the procedure on the other leg. • Record the response. Biceps Jerk or Reflex • Ask the subject to sit comfortably. • Ask the subject to extend the arm at elbow. • Then ask the subject to flex his/her elbow to a right angle and keep the forearm in semipronated position. • Palpate the biceps tendon and place your thumb of your non-dominant hand on the bicep tendon. • Support the subject’s arm with rest of your fingers and palm of non-dominant hand. • Using the pointed end of a reflex hammer to strike a sharp stroke over your thumb. • Observe the contraction of biceps muscle and flexion of elbow (Fig. 8.3). • Repeat the procedure on the other hand. • Record the response.

Fig. 8.3: Elicitation of biceps jerk

Supinator Jerk or Reflex • Ask the subject to sit comfortably. • Ask the subject to extend the arm at elbow. • Then ask the subject to flex his/her elbow to a right angle and keep the forearm in semipronated position. • Support the subject’s arm with your non-dominant hand. • Strike the supinator tendon around 3 to 4 cm above styloid process with the broad end of the reflex hammer. • The strike delivery should be sharp enough. • Observe the contraction of the supination muscle which will be leading to supination of elbow (Fig. 8.5). • Repeat the procedure on the other hand. • Record the response. Jaw Jerk or Reflex • Ask the subject to open his or her mouth slightly but not too widely.

Fig. 8.4: Elicitation of triceps jerk

Demonstration of Reflex Activity

Fig. 8.5: Elicitation of supinator jerk

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Fig. 8.7: Elicitation of abdominal reflex

• Place one of your nondominant hand finger firmly on his/her chin. • Then tap suddenly with your dominant hand finger or gently strike on it in with pointed end of reflex hammer. • Observe the upward jerk of the jaw which will be leading to closure of the mouth (Fig. 8.6). • Record the response. SUPERFICIAL REFLEXES Abdominal Reflex • Ask the subject to lie down comfortably on the examination couch. • Gently scratch the skin of abdominal wall with the tip of a key from the lateral side towards the midline. • Observe the contractions of the abdominal wall (Fig. 8.7). • Repeat the procedure in all four quadrants of the abdomen (Fig. 8.8).

Fig. 8.8: Scratching technique in quadrants of the abdomen

• Scratch below and parallel to the costal margin from the lateral end to the midline to check the upper quadrant. • Scratch above the line joining the iliac crest and pubic symphysis to check the lower quadrant. Plantar Reflex

Fig. 8.6: Elicitation of jaw jerk

• Ask the subject to lie down comfortably on the examination couch. • Hold his/her foot with your nondominant hand. • Stimulate the outer edge of the sole of the foot by gently scratching a key from the heel towards the little toe and then medially up to the base of the big toe (Fig. 8.9). • Observe the movement of toes. Normal response: Plantar flexion of the great toe and it will draw together all the other toes (Fig. 8.10). Abnormal response (Babinski’s sign): Extension of great toe and fanning of other toes (Fig. 8.11).

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Fig. 8.9: Stimulus application technique of planter reflex

Fig. 8.11: Babinski’s sign

Fig. 8.10: Elicitation of planter reflex

Fig. 8.12: Conjunctival reflex

Conjunctival Reflex

Direct Light Reflex

• Ask the subject to sit comfortably. • Ask the subject to keep his/her eye open and look at the opposite side without rotating the neck. • Touch the conjunctiva with a wisp of cotton from the side (Fig. 8.12). • Observe the closure or blinking of the eyelid. • Repeat the procedure on the other eye. • Record the response.

• Ask the subject to sit comfortably. • Ask the subject to close one of his/her eye and fix the gaze of a distant object. • Focus a beam of light on the cornea by bringing a torch from the side. • Observe the constriction of pupil. • Repeat on the other eye. • Record the response.

Corneal Reflex • Ask the subject to sit comfortably. • Ask the subject to keep his/her eye open and look at the opposite side without rotating the neck. • Touch the cornea very gently with a wisp of cotton. • Observe the closure or blinking of the eyelid. • Repeat the procedure on the other eye. • Record the response.

Indirect Light Reflex • Ask the subject to sit comfortably. • Ask the subject to place a non-transparent separator between the eyes over his/her nose. • Focus a beam of light on his cornea by bringing a torch from the side. • Look for constriction of the pupil of the other eye. • Repeat on the other eye. • Record the response.

Recording of Body Temperature

9

INTRODUCTION

Procedure of Oral Temperature Measurement

Body temperature represents the balance between heat production and heat loss. If the rate of heat generated equates to the rate of heat lost, the core body temperature will be at stable condition. All metabolising body cells manufacture heat in varying amounts. Therefore, body temperature is not evenly distributed across all the body. Body temperature is one of the four main vital signs that must be monitored to ensure safe and effective care.

a. Oral b. Axilla (armpit) c. Rectal d. Ear canal e. Forehead

• Clean the clinical glass thermometer and dry it properly. • Hold the thermometer at the upper end. • Shake the thermometer to direct mercury column at the lower end (bulb part at the tip). • Place the thermometer in oral cavity just below the tongue. • Instruct the subject to hold the thermometer firmly by using the lips (not with the help of teeth). • Wait for at least two minutes. • Then hold the thermometer and instruct the subject to open the mouth. • Remove the thermometer from the oral cavity. • Hold the thermometer at eye level and read the mark up to which mercury column reach. • Enter the observation in note book.

ORAL TEMPERATURE MEASUREMENT

AXILLARY TEMPERATURE MEASUREMENT

Oral temperature measurement is the most common method to measure body temperature in adult subject. If subject is contentiously sneezing, coughing, shivering or in unconscious stage then this method should be avoided.

This is the safest place to measure body temperature. But in this method we get little bit lower temperature in comparison to the core body temperature.

LOCATION OF BODY FOR TEMPERATURE MEASUREMENT

Apparatus Required Clinical glass thermometer and stopwatch.

Apparatus Required Clinical glass thermometer (Fig. 9.1) and stopwatch. Clinical Glass Thermometer One bulb (mercury reservoir) is present at the tip of the thermometer. Clinical glass thermometer has a loop or constriction in the inner tube so that once the mercury column cross the loop or constriction it cannot go down again until it is shaken. If you do not shake the thermometer it will result in an inaccurate reading. Two types of graduation scales are present on the outer glass wall of thermometer. One scale is in Fahrenheit and other one is in Celsius.

Fig. 9.1: Clinical glass thermometer for oral and axillary tempe­ rature measurement

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Procedure of Axillary Temperature Measurement • Clean the clinical glass thermometer and dry it properly. • Hold the thermometer at the upper end. • Shake the thermometer to direct mercury column at the lower end (bulb part at the tip). • Place the bulb part of clinical glass thermometer in the centre of axilla (armpit). • Instruct subject to hold the thermometer firmly by adducting the upper arm close to the midaxillary line and by placing the forearm across the chest. • Leave the thermometer on that place for 3–4 minutes • Then hold the thermometer and remove the thermometer from axillary region of subject. • Hold the thermometer at eye level and read the mark up to which mercury column reach. • Enter the observation in notebook.

AUDITORY CANAL OR TYMPANIC TEMPERATURE MEASUREMENT This method gives an accurate picture of internal body temperature. Apparatus Required Tympanic thermometer and stopwatch. Tympanic Thermometer It has a projection at the upper part which has a infrared probe or prod (can sense the infrared energy). This probe is covered by a disposable envelop. This particular part is inserted into the ear canal. Tympanic thermometer can sense the infrared energy which is emitted from internal auditory canal and then display the temperature digitally on the display area. Procedure of Auditory Canal or Tympanic Temperature Measurement

Apparatus Required

• Clean the probe of tympanic thermometer and dry it properly. • Insert the tympanic thermometer into the external auditory canal. • Press and hold the button present in body part of the tympanic thermometer to record the temperature. • After few seconds record the temperature displayed in display LCD part of thermometer. • Enter the observation in note book.

Rectal thermometer and stopwatch.

FOREHEAD TEMPERATURE MEASUREMENT

Rectal Thermometer

This method does not give an accurate picture of body temperature.

RECTAL TEMPERATURE MEASUREMENT This is the most accurate method to measure core body temperature. This method takes more time to achieve core body temperature. This method mainly used in infants and children. In this method privacy should be maintained properly.

One bulb (mercury reservoir) or probe is present at the tip of the thermometer. This bulb is smaller and rounded than clinical glass thermometer. Two types of graduation scales are present on the outer glass wall of thermometer. One scale is in Fahrenheit and other one is in Celsius. Procedure of Rectal Thermometer Measurement • Clean the rectal thermometer and dry it properly. • Hold the thermometer at the upper end. • Apply lubricant jelly (water based) on the probe or bulb part at the tip. • Gently insert the rectal thermometer 5 to 7 cm in the rectum. • Leave the thermometer on that place for 4–5 minutes • Then hold the thermometer at the end part and remove the thermometer gently from rectal region of subject. • Hold the thermometer at eye level and read the mark up to which mercury column reach. • Enter the observation in notebook.

Apparatus Required Band thermometer and stopwatch. Band Thermometer It is a typical band like structure. It is a plastic strip thermometer. Temperature sensitive marking are present on the band. It is mercury free and flexible. Procedure of Forehead Temperature Measurement • Dry the subject’s forehead completely before sticking or placing band thermometer. • Stick the band thermometer if it is sticky or hold the band thermometer at both ends and press flat against the forehead (half inch above the eye brows). • Hold or stick for at least 20–30 seconds. • Observe the color change while it is in the forehead to get the body temperature. • Green color indicates the body temperature of the subject (color changing option as indicator of body temperature may vary with different manufacturer are present in details within the band thermometer packet). • Enter the observation in notebook.

Recording of Body Temperature

TEMPORAL ARTERY TEMPERATURE MEASUREMENT This method does not give an accurate picture of body temperature. But in this method temperature can be measured in infants during sleep also. Apparatus Required Temporal artery thermometer and stopwatch. Temporal Artery Thermometer It has a small projection at the upper part which has a infrared probe or prod. This probe can sense the infrared energy which is emitted from the skin over temporal artery. This probe has no cover.

OBSERVATION EXERCISE

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Procedure of Temporal Artery Temperature Measurement • Place the temporal artery thermometer at the centre of forehead of subject. • Press and hold the button present in body part of the temporal artery thermometer. • Slide the probe horizontally on the forehead towards the hairline. • After few seconds record the temperature displayed in display LCD part of thermometer. • Enter the observation in notebook.

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Demonstration of Positive and Negative Feedback Mechanism Experiments record resting blood pressure in sitting position before starting exercise. • Record pulse rate or heart rate, blood pressure, body temperature using standard procedures. • Record the breathing rate by counting one single rise of the chest followed by fall the chest as one respiratory cycle (consist of one inspiration and one expiration). • Prick the ring finger under aseptic condition. Take a drop of blood on pH indicator paper and check the pH range of blood. • Ask the subject to perform exercise for at least five minutes (either ask subject to do Harvard Step Test or Astride jump test for 5 minutes). • Exercise should be performed in light and comfortable clothing and after two hours of light breakfast. The subject should not take caffeine, nicotine, alcohol and non-essential drugs before the exercise. • Record the pulse rate or heart rate, blood pressure, body temperature using standard procedures immediately after stoppage of exercise and also 10 minutes after stoppage of exercise. • Record the breathing rate by counting one single rise of the chest followed by fall the chest as one respiratory cycle (consist of one inspiration and one expiration) immediately after stoppage of exercise and also 10 minutes after stoppage of exercise.

PRINCIPLE Homeostasis is maintenance of equilibrium in the body’s internal environment by constant interaction of its regulatory mechanisms. Feedback mechanism is one of the most important and effective mechanism of regulatory mechanism. Feedback mechanism can either be positive or negative. Positive feedback mechanism occurs when change in the parameter triggers a response that causes changes in the same direction. And in the negative feedback mechanism, a stimulus causes an opposite output reversing the initial change in order to maintain the normal level of the parameter to be regulated. The changes occurs in the body due to exercises are very good example of positive and negative feedback mechanisms. Positive feedback mechanism works during exercise to: • Increase oxygen demand by the muscles • Increase heart rate • Increase in systolic blood pressure • Increased body temperature • Reduce pH of blood Negative feedback mechanism works during exercise to: • Increase respiratory rate or breathing rate • Decrease diastolic blood pressure REQUIREMENTS Sphygmomanometer, stethoscope, stop watch, sterile lancet or pricking needle, cotton swab dry, cotton swab soaked in alcohol, clinical thermometer, pH indicator paper.

• Prick the ring finger under aseptic condition imme­ diately after stoppage of exercise. Take a drop of blood on pH indicator paper and check the pH range of blood and also 10 minutes after stoppage of exercise.

PROCEDURE

OBSERVATION

Demonstration of Positive and Negative Feedback Mechanisms • Ask the subject to sit comfortably and relax (mentally and physically) for 5 minutes and then after 5 minutes 94

Subject’s name

: _____________________

Age

: _____________________

Gender

: _____________________

Demonstration of Positive And Negative Feedback Mechanism Experiments Pulse/heart rate (beats per minute) palpate from carotid artery Resting condition (before starting exercise) Immediately after Stoppage of exercise After 10 minutes of stoppage of exercise

OBSERVATION EXERCISE

Systolic blood pressure (mm of Hg)

Diastolic blood pressure (mm of Hg)

Body temperature (°C)

95 Respiratory cycle (cycles/min)

pH of blood

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Determination of Tidal Volume and Vital Capacity

PRINCIPLE Spirometer is a simple instrument which is designed to collect expired air from subject. Volume of expired air can be measured by this instrument. The volume of air which can be exhaled after quite inspiration by quiet expiration mechanism is known as tidal volume. The volume of air which can be exhaled by maximum forceful expiration process after maximum forceful inspiration is known as vital capacity. REQUIREMENTS Spirometer (Figs 11.1A and B); potassium permanganate solution. Spirometer This is a simple instrument which is designed to collect expired air from subject. Volume of expired air can be measured by this instrument. Fig.11.1B: Spirometer

It consists of double walled metal cylinder filled with water into which an inverted cylinder (bell) of six liters capacity is present. This inverted cylinder can be lowered or raised with the help of a chain that passes over pulley calibrated in liters. The chain is hanging down with a counter balancing weight tied to it. The pulley is fitted with an indicator needle. Needle indicates the amount of air present in the bell. The reading is obtained from graduated dial. Water in outer cylinder acts as a seal for the gas collected in the bell. For collection of expired air, the inlet of the bell can be connected to the subject by a corrugated tube and a mouthpiece. PROCEDURE Measurement of Tidal Volume • Before starting the experiment, mouthpiece should be cleaned with potassium permanganate solution.

Fig.11.1A: Spirometer

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Determination of Tidal Volume and Vital Capacity

• Bell should be gently pushed down to the lower most position. • After that adjust the pointer needle (on pulley) at zero to ensure that the bell is completely empty. • Ask the subject to stand comfortably in close proximity to spirometer and facing the towards the spirometer to see the movement of bell. • Ask the subject to breathe normally (quiet breathing) for 5 to 6 minutes. • After that ask the subject to close both the nostrils with clip provided with instrument or with the help of thumb and fingers of left hand, and ask him/her to hold the mouthpiece firmly between the lips by right hand. • In this position, ask the subject to exhale air with normal expiration (quiet expiration). The bell moves up and the pointer on the pulley indicates the volume of expired air. • Take at least three recording at an interval of 5 minutes • Repeat this procedure after changing the posture from standing to sitting. • Note all the result in observation table. Measurement of Vital Capacity • Before starting the experiment, mouthpiece should be cleaned with potassium permanganate solution. • Bell should be gently pushed down to the lower most position. • After that adjust the pointer needle (on pulley) at zero to ensure that the bell is completely empty. • Ask the subject to stand comfortably in close proximity to spirometer and facing the towards the spirometer to see the movement of bell. OBSERVATION EXERCISE

97

• Ask the subject to breathe normally (quiet breathing) for 1 to 2 minutes. • After that ask the subject to breathe as deeply and forcibly with maximum effort as possible to fill the lungs. • After that ask the subject to close both the nostrils with clip provided with instrument or with the help of thumb and fingers of left hand, and ask him/her to hold the mouthpiece firmly between the lips by right hand. • In this position, ask the subject to exhale air with maximum forceful expiration into the mouthpiece. • The bell moves up and the pointer on the pulley indicates the volume of exhaled air. Take at least three recording at an interval of 5 minutes. • Repeat this procedure after changing the posture from standing to sitting. • Note all the result in observation table. OBSERVATION Subject’s name Age Gender

: _____________________ : _____________________ : _____________________ Standing position

Tidal Volume (ml)

1st reading 2nd reading 3rd reading

Vital capacity(ml)

1st reading 2nd reading 3rd reading

Sitting position

12 Systems of the Body Label the various parts in the following figures. STUDY OF DIGESTIVE SYSTEM

Fig. 12.1: Parts of human digestive system

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Systems of the Body

Fig. 12.2: Histology of the alimentary canal

Fig. 12.3: Accessory organs of digestive system

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STUDY OF CARDIOVASCULAR SYSTEM

Fig. 12.4: Chambers of the heart

Fig. 12.5: Conduction system of the heart and spread of impulse

Systems of the Body

Fig. 12.6: Normal electrocardiogram

Fig. 12.7: Heart sounds

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Fig. 12.8: Arterial supply of heart

Fig. 12.9: Coronary sinus and associated veins

Systems of the Body

STUDY OF RESPIRATORY SYSTEM

Fig. 12.10: Human respiratory system

Fig. 12.11: Sagittal section pharynx

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STUDY OF URINARY SYSTEM

Fig. 12.12A: Component of urinary system

Fig. 12.12B: Cut section of kidney with ureter and urinary bladder

Systems of the Body

Fig. 12.13: Coronal section through the kidney showing the naked eye structure

Fig. 12.14: Placement of the uriniferous tubule/nephron in various zones of kidney

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Fig. 12.15: Juxtaglomerular apparatus

Fig. 12.16: General course of the ureter in the pelvis

Systems of the Body

Fig. 12.17: Innervation of the bladder

STUDY OF REPRODUCTIVE SYSTEM

Fig. 12.18: Ovaries and their relationships to uterine tube and uterus

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Fig. 12.19A: Histology of ovary

Fig. 12.19B: Graafian follicle

Systems of the Body

Fig. 12.20: Uterine and ovarian arteries and ureter being crossed by uterine artery

Fig. 12.21: Effects of hormones leading to ovarian cycle including phases of endometrium in menstrual cycle

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Fig. 12.22: Mammary glands of female

Fig. 12.23: Male reproductive organs

Systems of the Body

Fig. 12.24: Transverse section through the body of the penis

Fig. 12.25: Anatomy of testis

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Fig. 12.26: Transverse section through the spermatic cord

Fig. 12.27: Spermiogenesis—spermatid

Recording of Body Mass Index

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Anthropometry is the most cost effective method of measurement of the human body to determine body built, obesity and body composites. MEASUREMENTS OF HEIGHT Principle The vertical distance from the standing surface to the vertex of the head or the top of the head when the subject stands erect and look straightforward. Apparatus Required Anthropometer (Fig.13.1) PROCEDURE • Assemble the anthropometer (Fig.13.2). • Ask the subject to stand erect (straight) with bare footed in a flat surface and with their weight evenly distributed on both feet. • Ensure that floor is flat and even. • Ask the subject to join both the heels together as much as possible, legs and trunk straight without stiffness

Fig.13.1: Anthropometer

Fig.13.2: Assembled anthropometer

and also ensure that subject do not lift heels from the floor during measurement. • Ask the subject to erect his/her head and look straightforward during the time of measurement. Ensure the head should be in the Frankfurt plane (an imaginary line connecting the drawn landmarks at right tragion and right orbitale should be in horizontal plane) (Fig.13.3). • Stand at one side of the subject and use an anthropometer to measure the vertical distance between the flat standing surface and the top of the head (vertex)(Fig.13.4). • Move the movable blade of the anthropometer across the top of the head and use little pressure to compress the subject’s hair to ensure the vertex. • Take the measurement at the maximum point of subject’s quiet respiration.

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Fig.13.5: Measurement of weight

Fig.13.3: Frankfurt plane

• And also ask the subject to stand with their weight evenly distributed on both feet. • Ask the subject to join both the heels together as much as possible, legs and trunk straight without stiffness and also ensure that subject do not lift heels from the electronic weighing scale during measurement (Fig. 13.5). • Ask the subject to erect his/her head and look straightforward during the time of measurement. Ensure the head should be in the Frankfurt plane. • Stand at one side of the subject and note the weight appeared in the electronic weighing scale. MEASUREMENT OF BODY MASS INDEX [BMI] Apparatus Required Anthropometer, electronic weighing scale. PROCEDURE • Measure height of the subject • Measure weight of the subject • Convert the measured height into meter unit and calculate the square value (m2). • After that calculate body mass index (kg/m2) of the subject by using the following formula. Fig.13.4: Measurement of height

Body mass index (kg/m2) =

MEASUREMENTS OF WEIGHT Apparatus Required Electronic weighing scale PROCEDURE • Ask the subject to stand erect (straight) with bare footed and with very light clothing on the center of the electronic weighing scale without any support and without touching any object.

Body weight (kg) [Height (m)]2

• Note the result and cheek the category of body mass index of the subject from following table. Category

BMI ( kg/m2)

Underweight