WHERE THERE IS NO DOCTOR HOW TO EXAMINE A SICK PERSON

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Title: WHERE THERE IS NO DOCTOR HOW TO EXAMINE A SICK PERSON
extracted text: COMMUNITY HEALTH 7?
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CHAPTER

How to Examine
a Sick Person

This is a reprint from

Where "There Is No Doctor
(Indian adaptation)

published by the
Voluntary Health Association of India
- C-14 Community Centre
Safdarjung Development Area
New Delhi 110016

COMMUNITY HEALTH CELL
CHAPTER

How to Examine
a Sick Person
■ To find out the needs of a sick person, first you must ask important questions
and then examine him carefully. You should look for signs and symptoms that
help you tell how ilI the person is and what kind of sickness he may have.

There are certain basic things to ask and to look for in anyone who is sick.
These include things the sick person feels or reports (symptoms), as well as things
you notice on examining him (signs). These signs can be especially important in
babies and persons unable to talk. In this book the word 'signs' is used for both
symptoms and signs.

Always examine the person where there is good light, preferably in the sunlight
-never in a dark room.
When you examine a sick person, write down your findings and keep them for
the health worker in case he is needed

QUESTIONS
Start by asking the person about
his sickness. Be sure to ask the
following:

What bothers you most right now?
What makes you feel better or
worse?
How and when did your sickness
begin?
Have you had this same trouble
before, or has anyone else in
your family or neighborhood
had it?
Continue with other questions in order to learn the details of the illness.
Eor example, if the sick person has a pain, ask him:
Where does it hurt? (Ask him to point to the exact place with one finger.)
Does it hurt all the time, or off and on?
What is the pain like? (sharp? dull? burning?)
Can you sleep with the pain?

If the sick person is a baby who still does not talk, look for signs of pain.
Notice his movements and how he cries. (For example, a child with an earache
sometimes rubs the side of his head or pulls at his ear.)

35

36

GENERAL CONDITION OF HEALTH
Before touching the sick person, look at him carefully. Observe how ill or weak
he looks, the way he moves, how he breathes, and how clear his mind seems.
Look for signs of dehydration (see p. 781) and of shock (p. 89).

Notice whether the person looks well nourished or poorly nourished. Has he
been losing weight? When a person has lost weight slowly over a long period of
time, he may have a chronic illness (one that lasts a long time).
Also note the color of the skin and eyes:

• Paleness, especially of the lips and inside the eyelids, is a sign of anemia
(p. 146).
• Bluish skin, especially blueness or darkness of the lips and fingernails, may
mean serious problems with breathing (p. 91 and 204) or with the heart
(p. 371).
• A grayish-white coloring, with cool, moist skin, often means a person is in
shock (p. 89)...
• Yellow color (jaundice) of the skin and eyes may result from disease in the liver.
hepatitis (p. 209) or cirrhosis (p. 374) or amebic abscess (p. 198) or gall
bladder (p. 375). It may also occur in new born babies (p. 320).

TEMPERATURE
It is often wise to take a sick person's temperature, even if
he does not seem to have a fever. If the person is very sick,
take the temperature at least 4 times’each day and write it down.
If there is no thermometer, you can
get an idea of the temperature by
putting the back of one hand on the sick
person's forehead and the other on your
own or that of another healthy person.
If the sick person has a fever, you should
feel the difference.
It is important to find out when and how the fever comes, how long it lasts,
and how it goes away. This may help you identify the disease. For example:
• Malaria usbally causes attacks of a high fever that begin with chills, last a few
hours, and come back every 2 or 3 days (p.227).
• Typhoid causes a fever that rises a little more every day (p. 229)
• Tuberculosis sometimes causes a mild fever in the afternoon. At night the
person often sweats, and the fever goes down (p. 219)
Note: In newborn babies a temperature that is unusually high or unusually low
(below 36°) may mean a serious infection (see p. 321).

■ To learn about other fever patterns, see p. 32 to 33.
■ To learn how to use a thermometer, see the next page.
• To learn what to do for a fever, see p 87.

37

How to Use a Thermometer
Every family should have a thermometer. Take the temperature of a sick
person 4 times a day and always write it down.

How to read the thermometer (using one marked in degrees centigrade—°C):

stops marks the temperature.

marks 40 degrees C.

How to take the temperature:
1. Clean the thermometer well with soap
and water or alcohol. Shake it hard, with
a snap of the wrist until it reads less than
36 degrees.

2. Put the thermometer. ..
under the tongue
(keeping.the
mouth shut)

or

in the armpit if there
is danger of biting
the thermometer

or

carefully, in the anus
of a small child
(wet or grease it first)

If the sick person is unconscious, put the
thermometer in the armpit or anus.
3.
4.

5.

Leave it there for 3 or 4 minutes.
Read it. (An armpit temperature will read a little lower than a mouth reading;
in the anus it will read a little higher.)

Wash the thermometer well with soap and water.

38

BREATHING (RESPIRATION)
Pay special attention to the way the sick person breathes—the depth (deep or
shallow), rate (how often breaths are taken), and difficulty. Notice if both sides
of the chest move equally when he breathes.

If you have a watch or simple timer, count the number of breaths per minute.
Between 12 and 20 breaths per minute is normal for adults and older children Up
to 30 breaths a minute is normal for children, and 40 for babies. People with a
high fever or serious respiratory illnesses (like pneumonia) breathe more quickly
than normal. More than 40 shallow breaths a minute usually means pneumonia.

If you do not have a watch to count the respiration, you can use your pulse rate to
count the respiration of the sick person
If the person takes one breath for every four beats of your pulse, then it is normal
rate. It he takes one breath for every two or three of your pulse then it means he is
breathing faster than normal
Listen carefully to the sound of the breaths. For example:
■ A whistle or wheeze and difficulty in breathing out can mean asthma (p.204)
' A gurgling or snoring noise and difficult, breathing in an unconscious person
may mean that the tongue, mucus, (slime or pus), or something else is stuck in the
throat and does not let air go through.
' Attacks of sudden breathlessness at night may mean heart disease (p.371)

Look for 'sucking in' of the skin between ribs and at the angle of the neck
(behind, the collar bone) when the person breathes in. This means air has trouble
getting through. Consider the possibility of something stuck in the throat (p. 91),
pneumonia (p 209), asthma (p.204), or bronchitis (mild sucking in, see p. 207).

If the person complains of breathing problems, ask him the following questions.
Any chest pain? If the chest pain becomes worse by breathing or coughing and il
the pain gets better by lying on the side, it means the beginning stages of
pneumonia (see p. 208)
• If the chest pain comes on during walking, running, climbing up
the stairs, and disappears on taking rest for a few minutes, it means
heart disease (see p.371)
If the person has a cough, ask him if it keeps him from sleeping. Find
out if he coughs up mucus, how much, its colour and if there is blood
in it.
* Dry early morning cough is mostly due to too much smoking.
’ Cough with large amounts of mucus which is white in
colour Bronchiectasis (p.2O8) or Chronic Bronchitis (p. 207)
* Cough with blood stained mucus, fever in the afternoon, and
weight loss — Tuberculosis (p.219). If the sick person is above
40 years old and smokes too much, he could have cancer of the lungs.
•

39

PULSE (HEARTBEAT)
To take the person's pulse,
put your fingers on the wrist
as shown. (Do not use your
thumb to feel for the pulse.)

If you cannot find the pulse
in the wrist, feel for it in the
■neck beside the voicebox

or put your ear directly On
the chest and listen for the
heartbeat.

Pay attention to the strength, the rate, and the regularity of the pulse. If you
have a watch or timer, count the pulses per minute.

NORMAL PULSE FOR PEOPLE AT REST
adults
children
babies

from 60 to 80 per minute
80 to 100
100 to 140

If you do not have a watch, you can get an approximate idea of the
sick person’s pulse rate by comparing it with your own. Be sure to do it
after you have rested for a few minutes, of your pulse rate will be faster
with the exertion.

The pulse gets much faster with exercise and when a person is nervous,
frightened'has a fever or is in acute pain? As a general rule, the pulse increases
20 beats per minute for each degree (°C) rise in fever.
When a person is very ill, take the pulse often and write it down along with the
temperature and rate of breathing.

It is important to notice changes in the pulse rate. For example:
• A weak, rapid pulse can mean a state of shock (see p 89),
• A very rapid, very slow, or irregular pulse could mean heart, trouble (see
p.371).
• A relatively slow pulse in a person with a high fever may be a sign of typhoid
(see p. 229).

40

EYES
Look at the color of the white part of the eyes. Is it normal, red (p. 263). or
yellow? Also note any changes in the sick person's vision.
Have the person slowly move his eyes up and down and from side to side.
Jerking or uneven movement may be a sign of brain damage.

Pay attention to the size of the pupils (the black 'window' in the center of the
eye). If they are very large, it can mean a state of shock (see p. 89) If they are
very small, it can mean poison or the effect of certain drugs.
Look at both eyes and note any difference between the two, especially in the
size of the pupils:

A difference in the size of the pupils is almost always a medical emergency.

• If the eye with the larger pupil hurts so badly it causes vomiting, the person
probably has GLAUCOMA (see p.267).
• If the eye with the smaller pupil hurts a great deal, the person may.have
IRITIS, a very serious infection (see p.266).

• Difference in the size of the pupils of an unconscious person or a person who
has had a recent head injury may mean brain damage. It may also mean
STROKE (see p.373).
Always compare the pupils of a person who is unconscious or has had a head
injury.

EARS
Always check for signs of pain and
infection in the ears—especially when you
examine a baby who has a fever or has had
a cold. A baby who cries a lot and rubs or
pulls at his ear often has an ear infection
(p.356).

k

41

If the skin behind the earlobe is red. then press that area. If this
causes severe pain, it means that the bone is infected. The person
usually has high fever and looks very ill. For treatment, see p.355

To look inside the ear, pull the ear gently with vour fingers, if this
causes increased pain, the infection is probably in the tubex of the ear
(ear canal).
Look for redness or pus inside the ear. A small torch will help But
never put a stick, wire or other hard object inside the ear.

Find out if the person hears well, or if one side is more deaf than the
other. (For deafness and ringing of the ear see page 373)

MOUTH, TONGUE AND THROAT
Examine the mouth, tongue and throat carefully, even if the person
does not seem very sick.
If there are cracks or sores at the corners of the mouth, this could be
a vitamin deficiency (see p. 276)
See the colour and the appearance of the tongue:
• pale and smooth — anemia (seep.146)
• blue — problems with breathing or the heart (see p.371)
' dry tongue is a sign of dehydration (see p 1811
• small white batches on the tongue may mean fungal infection
(see p. 276)
• any old sore that does not heal, on the tongue or inside the mouth
may be cancer. This is very common in places where people
chew betel leaves with slaked lime and tobacco. Consult a
health worker.
Co see the back of the throat, press the tongue with the back of a

The tonsils are two small lumps on either side of the tongue at the
back of the throat. When the tonsils are affected, it is tonsillitis (see P.356)
The tonsils become big and the child has fever. This is one of the most
important causes of fever in children.
—
White or greyish patches on the tonsils and back of the throat in
, ,
small children may mean diptheria (see p. 361).

42

SKIN
It is important to examine the sick person's body, no matter how mild the
sickness may seem. Babies and children should be undressed completely. Look
carefully for anything that is not normal, including:

• sores
• rashes or welts
• wounds
• splinters

• spots, patches, or any unusual
markings

• swollen lymph nodes (little
lumps in the neck, the armpits,
or the groin, see p. 101)
• unusual thinning or loss of hair,
or loss of its color or shine (p. 125)

• loss of eyebrows (leprosy? p. 232)

• inflammation (sign of infection
with redness, heat, pain, and
swelling)
• swelling

• abnormal lumps or masses
Always examine little children
between the buttocks, in the
genital area, between the fingers
and toes, behind the ears, and in
the hair (for lice, ringworm,
rashes, and sores).
For identification of different
skin problems see page238-240

THE BELLY(ABDOMEN)
If a person has pain in the belly, try to find out exactly where it hurts.
Learn whether the pain is steady or whether it suddenly comes and goes, like
cramps or colic.

When you examine the belly, first look at it for any general swelling.
swelling in a particular area or part, or lumps.

The location of the pain often gives a clue to the cause (see p. 44 ).

43

First, ask the person
to point with one finger
where it hurts.

Then, beginning on the opposite side from the spot
where he has pointed, press gently on different parts
of the belly to see where it hurts most.

See if the belly is soft or hard and whether the person can relax his stomach
muscles. A very hard belly could mean an acute abdomen—perhaps appendicitis
or peritonitis (see p. 108)

To make the abdomen relax, ask him to bend his legs at the knees.
as shown.

If you suspect peritonitis or appendicitis, do the test for rebound pain described
on page 108

Feel for any abnormal lumps and hardened areas in the belly.
If the person has a constant pain in the stomach, with nausea, and has not been
able to move his bowels, put an ear on the belly, like this:

Listen for gurgles ih the
intestines. If you hear
nothing after about 2
minutes, this is a danger sign.
(See Emergency Problems of
the Gut, p. 10ti)

A silent belly is like a silent dog. Beware!

44

These pictures show the areas of the belly that usually hurt when a person has
the following problems:

Ulcer
(see p.1 49)

pain in the
‘pit of thestomach’

Gallbladder
(seep. 375)

the pain often
reaches to
the back

Urinary system
(see p. 278)

mid or
low back pain;

often goes around
the waist to the
lower part of
the belly

Inflammation or
tumor of the ovaries,
etc. (see p 326)

pain on one
side or both,
sometimes
spreading to
the back

urinarytubes
bladder

Note: For different causes of back pain see p. 211

45

MUSCLES AND NERVES
If a person complains of numbness, weakness, or loss of control in part of his
body, or you want to test for it: notice the way he walks and moves. Have him
stand, sit, or lie completely straight, and carefully compare both sides of his body.

Face: Have him smile, frown, open his eyes wide, and
squeeze them shut. Notice any drooping or weakness on one
side.

If the problem began more or less suddenly, think of a
head injury (p104), stroke (p.-373) or Bell's palsy
(p. 373)

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If it came slowly, it may be a brain tumor. Get medical advice.

Also check for normal eye movement, size of pupils (p.26O), and how well he
can see.

Arms and legs: Look for loss of muscle. Notice—or measure—difference in
thickness of arms or legs.

Have him lie down and lift one leg
and then the other.

Also have him hold his arms straight
out and turn his hands up and down.

Note any
weakness or
trembling.

If muscle loss or weakness affects the whole body, suspect malnutrition (p. 132)
or a chronic (long-term) illness like tuberculosis.
If muscle loss and weakness is uneven or worse on one side, in children, think
first of polio (p.-361); in adults, think of a back problem, a back or head injury,
or stroke.

46

Check for stiffness or tightness of different muscles:

• If the jaw is stiff or will not open, suspect tetanus (p. 223)
or a severe infection of the throat (p 356). or of a tooth (p. 275).

• If the neck or back is stiff and bent
backwards, in a very sick child, suspect
meningitis. If the head will not bend
forward or cannot be put between the
knees, meningitis’is likely (p. 225).
• If a child always has some stiff muscles and makes strange or jerky
movements, he may be spastic (p.367 ).
• If strange or jerky movements come suddenly, with loss of consciousness, he
may have fits (p. 21 7). I f fits happen
often, think of epilepsy. If they
happen when he is ill, the cause may
be high fever (p. 88) or dehydration
(p. 181) or tetanus (p. 222).

To test a person's reflexes when you suspect tetanus, see p. 224

To check for loss of feeling in the hands, feet, or other
parts of the body:

Have the person cover his eyes. Lightly touch
or prick the skin in different places. Ask him to say
'yes' when he feels it.

Loss of feeling in or near spots or patches on the
body is probably leprosy (p.232).

Loss of feeling in both hands or feet
may be due to diabetes (p. 149) or
leprosy.
Loss of-feeling on one side only could
come from a back problem (p. 212) or
injury.

47

Feet
Check to see if there is any swelling
of the feet. Normally swollen feet
can be made out just by looking at
the feet. If the swelling is very
little then press the skin over the
ahkle against the bone. In case
there is swelling, a small depression
will be made.
Small children who are
malnourished often have swollen
feet and face (see p.1 32)
Swollen feet are especially important in pregnant women, (see p. 214)
The feet are swollen if the kidneys are not working properly (see p.278)or
if there is something wrong with the heart, (see p. 371)
Elephantiasis (see p.'229) also results in swollen feet, and groins.
To find out if the patient has elephantiasis, press the skin above the
ankle as shown above. If the patient has elephantiasis, there
will be no depression in the skin after your remove your fingers.

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