Double Vision

Double Vision

PKGhatak,MD

If we cover one eye and look at an object, we see it as one, then remove the cover and look at the same object with both eyes we still see it as one. How is it possible?

It is the coordinated movements of eye muscles turning eyes in such a way that the image is formed on the corresponding points of each retina.

Six muscles move each eye in all possible directions; the muscles, in turn, are supplied by three cranial nerves. The one called the 3^rd cranial nerve supplies all but two muscles of the same side. The remaining muscles are supplied by the 4^th and the 6^th cranial nerves. The coordinated movement controller of the 3^rd, 4^th and 6^th cranial nerves are located in the cerebral cortex of the brain and by direct connections and relays it makes the eyeballs move in a harmonious fashion and keep the visual axis parallel.

In normal people when an object is placed very close, next to the nose, both eyeballs rotate inwards the visual axes converge and the image appears as double.

Muscles of the eyes may be damaged in accidents and certain diseases like Myasthenia gravis and Graves disease of the thyroid gland. The image of the involved eye may not land on the corresponding points on the retina of the normal eye. The image produced by the involved eye is called a false image and appears on the outside edge of the image produced by the normal eye. As the object is moved gradually further away from the eye involved two images appear further and further apart.

Diabetes is the most common cause of damage to the cranial nerves besides injuries of the face and orbit in automobile accidents. Damage to the 6^th cranial nerve in particular and other cranial nerves may occur in the situation resulting in an increase in cerebrospinal fluid pressure as seen in head injury, intracranial bleeding, and brain and meningeal tumors. Enlarging brain aneurysm, tumors of the pituitary gland and meningitis may damage cranial nerves. Stroke may damage nerve centers. A migraine and decreased blood flow of the brain stem can produce intermittent double vision. Multiple Sclerosis patients may present with double vision. Alcoholic encephalopathy and inflammatory polyneuritis can cause double vision. Parkinson's disease may cause double vision when objects are placed close to the eyes.

Infection of the central part of the face may spread to the brain and may cause double vision. Immunosuppressed patients, diabetics and patients taking prednisone are venerable to certain fungal infections of nasal sinuses, which may spread to the brain and cranial nerves and may result in double vision.

Diseases affecting one eye, leaving the other one untouched, may cause double vision. In astigmatism the curvature of one cornea unevenly changes and may cause double vision, in some other conditions corneal optical property may change; a developing cataract of the eye lens similarly may produce double vision. Retinal diseases or growth behind the retina may distort the retina and may lead to double vision.

Double vision may be an important symptom of an underlying serious illness. It should never be neglected and should always be checked out by a doctor within a day or two.

 

edited 2

 

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A Sluggish Thyroid Gland

A Sluggish Thyroid Gland

PKGhatak,MD

The Thyroid gland produces a hormone called Thyroxine. Thyroxine is essential to all living cells and must be supplied constantly just like oxygen and sugar. It controls all chemical activities of the body acting like a metabolic thermostat. When the blood levels of thyroxine fall below the normal levels the condition is known as Hypothyroidism. It may be a temporary condition as seen in acute serious illness, prolonged malnutrition, and starvation; the thyroid function will return to normal with the reversal of the primary condition. When a disease affects the thyroid gland hypothyroidism will persist unless proper treatment is undertaken.

The thyroid gland has the shape of a monarch butterfly with wings half open. The gland is located in the neck below Adam’s apple and in front of the windpipe. It has a very rich blood supply. The thyroxine enters directly into the blood supply. The thyroid gland is under the control of the Anterior pituitary gland, which is located inside the skull below the brain, above the roof of the nose and in between the eyes. When the Anterior pituitary senses thyroid function is falling it sends out a chemical messenger – Thyroid Stimulating Hormone (TSH) to boost the thyroid gland activity. As production of the thyroxine increases the anterior pituitary scales back TSH release. This process of check and balance is known as the negative feedback loop.

The main hormone Thyroxine has four Iodine atoms bound to an amino acid Tyrosine (T4). In addition, the Triiodothyronine hormone (T3), containing three atoms of iodine is also produced by the thyroid gland in a smaller amount. Both T4 and T3 are carried in the blood bound to plasma proteins, and only a tiny amount (0.05%) remains free and is metabolically active. They are called Free T4 and Free T3 respectively. Though T3 in the blood is present in a smaller amount it plays a dominant role. It is 3 to 5 times more active than T4; it acts faster, disappears faster and is bound loosely to plasma proteins. In the tissues, most of the T4 is converted to T3 before it acts on the cells. In the thyroid gland, 80% of thyroid hormone is T4 and the rest 20% is T3. In blood T4 to T3 ratio is 40: 1.

We take in about 100 to 400 micrograms (mcg) of Iodine daily with food and drinks. The thyroid gland needs about 30 mcg of dietary iodine and the rest of the iodine is obtained by recycling the breakdown products of thyroxine. The thyroid gland takes up iodine from the blood by an active process because iodine concentration in the thyroid gland is higher than that of blood. The iodine is oxidized to iodide and then attached to the tyrosine residues of a glycoprotein. Cells of the thyroid follicle pick up iodinated glycoprotein and convert it into T4 and T3 within the follicular cells. And then release T4 and T3 in the blood when needed. Each and every one of these four steps of hormone production and subsequent release is controlled by TSH. At each stage, a specific enzyme is required for the completion of the process.

Decreased levels of circulating thyroid hormone will initiate the release of TSH from the anterior pituitary gland. TSH blood level is an accurate and sensitive test for the detection of hypofunction of the thyroid gland. TSH test has replaced most of the other tests used in earlier years. TSH is extremely useful in monitoring patients on thyroid replacement treatment and during pregnancy. A developing fetus starts making thyroxine at 18 weeks; in the second trimester mother’s blood supplies a good part of thyroxine to the growing child. If a mother is hypothyroid and remains untreated, the child will have a low IQ and even mental retardation.

Iodized salt, bread, milk and saltwater fish are the major source of iodine for the population in the USA. The population of countries deficient in dietary iodine and others who are unable to metabolize iodine because of high consumption of cassavas and turnips in their diet suffers from chronic iodine shortage. As a consequence, the thyroid gland enlarges. Many people present with an enlarged gland (goiter), and this condition is called Endemic Goiter. They may or may not show signs of hypothyroidism. But left untreated, most of them will have some complications in the long run. The treatment of endemic goiter is to supply Iodized salt or other forms of iodine in the diet.

Congenital deficiency of enzymes responsible for iodine transport or its incorporation into the glycoprotein and subsequent production of thyroxin may result in congenital hypothyroidism. These cases are rare. In still rare instances a child may be born without a thyroid gland. Often the disorder is not detected at birth because a mother has supplied thyroxine during pregnancy and by breastfeeding. A child presents with an enlarged thyroid gland at times the gland may have grown ten times the normal size. Such a Cretin child, as it is called, has a puffy face, enlarged tongue, and low forehead, increased hair, umbilical hernia and sluggish response to stimuli. Various neurological deficits, from deafness to paraplegia may be present. If treatment is delayed then mental retardation, deafness, muteness, stunted growth may be permanent.

The signs and symptoms of hypothyroidism are variable depending upon the severity and duration of the condition. Patients may complain of tiredness, fatigue, and weight gain, depression, falling asleep at inappropriate times and constipation. In some cases, muscle pain, pain in joints and effusion of knees are present. Cold sensitiveness, deafness, a decrease in taste and smell sensations may be present. A large tongue, non-pitting edema, puffy and watery eyes, menstrual disturbances in the female, thinning of hair and loss of the outer half of eyebrows, coarse skin, carpal tunnel syndrome may be present on examination. In some cases, fluid in the pericardial sac, pleural cavities, and ascites may be present. Patients may have slow mentation, confusion, and somnolence. The term Myxedema is used in the hypothyroid patient when weight gain, non-pitting edema, low serum sodium and fluid overload are present. Various psychiatric symptoms from disorientation, hallucination, paranoia, and psychosis in myxedema are commonly referred to as myxedema madness. In severe cases, a coma may result. When a patient presents with a myxedema coma the chance of survival is very poor.

In a given patient the precise cause of hypofunction of the thyroid gland may remain unknown. Viral infections either directly or by inducing an autoimmune response may damage the thyroid gland. Lymphocytic infiltration of the thyroid gland and subsequent hypofunction known by Hashimoto thyroiditis is well known. Infectious mononucleosis may damage the thyroid gland. Radiation to the neck, chest, and shoulder can damage the thyroid gland and result in decreased function. People with hepatitis C infection may develop autoimmune thyroiditis. Drugs used in the treatment of seizures like Dilantin, and Phenobarbital can lower T4 levels. Other drugs like Lithium and Amiodarone, Phenylbutazone, Sulfonamides Interferon alpha, and beta have significant adverse effects on thyroid function. Cancer, Sarcoidosis and thyroid surgery, and previous treatment with radioactive iodine may damage part or whole of the thyroid gland. TSH may be elevated in autoimmune diseases, acute psychiatric illnesses and in the elderly. Many drugs used in the treatment of various diseases may cause hypothyroidism or drugs may interfere with T4, T3, and TSH tests. One should be careful in interpreting those test results correctly.
In certain conditions of the Anterior Pituitary less than the normal amount of TSH is secreted, this results in decreased production of thyroxine. This condition is called Secondary Hypothyroidism.

The treatment of Hypothyroidism consists of: -
1. To supply thyroid hormone in the form of oral tablets.
2. Proper follow up with the adjustment of thyroid dose over the lifetime of a patient.
One tablet a day dose is inexpensive and effective. Iron and calcium tablets taken with thyroid medication interfere with the absorption of thyroid hormone. An antacid containing aluminum hydroxide, soy milk, proton-pump-inhibitor and many other agents also interfere with thyroid hormone absorption. It is recommended that thyroid tablets should be taken without other medications. The bioavailability of T4 varies from brand to brand. It is better to stay with one name brand or one manufacturer of a generic thyroid drug.
The results of hormone replacement therapy are excellent. Only in far advanced cases and in myxedema coma the results are not good.

 

 

 

revised 2020

Human Hair

HUMAN HAIR

PKGhatak,MD

The hair is an appendage of the skin. The entire skin surface is covered with hair except on the palms of hands and soles of feet. Human hair is subdivided into two categories.

1. Terminal Hair. The coarser hairs that are present on the scalp, eyebrows, eyelashes, nostrils, under the armpits, pubic area; and in men mustaches and beards.

2. Body Hair. The finer hair covers the rest of the body.

Each hair has a bulbous end called a hair Follicle located in the deep layers of skin. It is supplied with nerve fibers and blood vessels. The part of the hair that remains underneath the superficial layer of skin (epidermis) is called the Root of the hair. The part of the hair on the top of the skin is called the Shaft. The cells of the hair follicles are responsible for the growth and maintenance of hair.

Under the microscope, the hair has loosely packed cells in the center called the Core. The core is surrounded by several layers of densely packed cells containing pigments, and a protein called Keratin; the outer layer of hair is made up of a single layer of cells called Cuticle.

The hair is surprisingly strong for its size. 100 strands of hair can support 20 lbs. of weight without breaking. Hair is wettable, soaks up water about a third of its weight. With air sacs in the core and water retaining property, the hair protects the head against strong sun and chill winds.

There is a small gland underneath the skin at the point where the hair emerges from the skin. It secretes a tiny amount of oil and the oil keeps hair shiny and silky looking. This oil coats all surfaces of straight hair evenly; in persons with wavy or kinky hairs the oil cannot get to the entire shaft uniformly and these types of hair look dry and disorderly.

The body hairs grow slowly, whereas scalp hairs grow about 1 inch in 3 months. The rate of growth is slower in older people and fastest in adolescence. Growth takes place at the root of the hair, and as hair grows it sprouts out of the skin surface. Each individual hair has its own life cycle; independent of its neighbors. It decides when to grow, when to rest and when to die and fall off. And then it begins to grow again and the cycle continues. Because we lose so few hairs at a time that we do not notice the hair loss. Hair on the scalp grows to shoulder length in 3 years and reaches waist length in 5 years. Generally, after 6 years growth stops and hair rests for a period of time and at the end of 6 to 7 years it dies and falls off. During its lifetime, a hair may grow 5 feet in length if not trimmed. In the Guinness Book of Records, you may find evidence of longer hair. Body hair has a shorter life and growth remains limited.

The keratin of hair gives hair its flexibility and strength. It is made of amino acids of which Cystine has a disulfide bond. This disulfide bond gives keratin its special properties. When hairs are treated with alkaline agents this disulfide bond is weakened and curly hairs could be strengthened or straight hair may be given a curly shape. Then an acidic agent is applied to neutralize alkali and to make the changes last longer. The color of hair is due to the presence of a pigment called Melanin produced at the root of the hair by cells called Melanocytes. Two types of melanin are produced by these cells. Long arms of these cells deposit the pigments in rows, like a string of pearls, in the cortex cells of the hair. One color is black and the other is red. By the various combination of these two pigments, hairs get various shades of black, brown, yellow and red. The gray color of hair is due to the presence of only a few melanin pigments, non-pigmented hair looks yellowish due to the color of keratin.

The terminal hair depends on Androgen for its regulation of longitudinal growth, thickness, and vigor, whereas Estrogen slows the growth rate but prolongs the growth period. The thyroid hormone maintains its health. Body hair depends mostly on thyroid hormone for its health and growth. Zinc and B vitamins, particularly pantothenic acid, is required for the nutrition of hair. Steroid hormone may slow or weaken roots of hairs when used for a prolonged period. Certain chemicals like arsenic are taken up by the hair and remain unchanged in hairs for years even after burials. Drugs used in cancer treatment may arrest the growth of all fast growing cells of the roots of hair all at the same time, making hairs fall off in 2 to 3 weeks. But after completion of treatment hair will grow back. Thallium used in cardiac stress laboratories may cause hair to fall for the same reason. Many other drugs may influence hair one way or other.

The roots of the hair are the living part of the hair. The shaft of hair is a dead tissue. The DNA of hair cells can help identify an individual.

In hair, we admire the texture, wave, color, and silkiness - all about a dead tissue and the living part is unseen and remains buried under the skin.

 

 

revised 2020

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Blood Sugar

Blood sugar

PKGhatak,MD

We need energy at all times just to stay alive and a higher rate of energy supply when we are engaged in activities. The lowest rate of energy requirement for an average person is 70 Kilocalories/hr. (Kcal); this is also called the Basic Metabolic Rate (BMR). The actual BMR varies according to height, weight, gender, age and ethnicity of the person and on the climate conditions.

The sugar that circulates in our blood is Glucose; table sugar is sucrose made up of one molecule each of glucose and fructose; milk sugar is lactose; a combination of glucose and galactose and fruits contain fructose. All sugars belong to a group called carbohydrates; also present in this group are- starch, dextrin, corn syrup, potatoes, wheat, cereal and rice. The body, for the most part, must break down starch and other sugars into glucose before turning glucose into energy. The human body is unable to break down cellulose, the most abundant carbohydrate in nature, the main constituent of trees and other vegetation. Cellulose provides the bulk of our daily meals.

As we eat food it gets mixed with saliva. Saliva contains an enzyme called Amylase and it begins to break down carbohydrates. The process continues in the stomach and in the upper small intestine where more amylase comes from the pancreas. As glucose is generated from other sugars and the breakdown of starch, it is picked up by the cells of the small intestine and then transported to the liver via blood. Any excess amount of glucose in the liver is converted into a complex glucose structure called Glycogen (commonly known as animal starch). The liver can easily turn glycogen into glucose and release it in circulation whenever there is a need. The muscles of our body store Glycogen as fuel for work.

Every living cell of the body has a chemical factory called Mitochondria. It is loaded with enzymes, catalysts, and a high-energy fuel packet called Adenosine Tri Phosphate (ATP). A chemical process called the Tricarboxylic acid cycle, better known as the Krebs cycle, is the main energy producing process in the body. We can view it as a furnace having three entry gates; one for the sugars, the other one for amino acids (derived from break down of proteins) and the third one for fatty acids (comes from fat). The products coming out of the Kerbs cycles are heat, ATPs, and other intermediate products. These intermediate products are in turn synthesized into fat, proteins, hormones, and other essential chemicals in the liver and other specific organs. Outside the mitochondria but within the cells, there is another process where glucose is directly converted into energy through a chemical pathway known as Hexose monophosphate shunt.

You must have known a friend or relative who would not add a grain of sugar in his coffee but at the same time drink two glasses of wine and finish half a bottle of ketchup over two hot dogs. They tend not to remember wine and prepared food containing carbohydrates. Yes, wine and drinks containing alcohol are carbohydrates. We eat about 300gm of carbohydrates on an average day; we need a minimum of 150 gm of carbohydrates daily in order to keep the chemical fire going in the body. When the minimum amount of carbohydrates is not present in the diet, the Krebs cycle will generate acetone from partially utilized amino acids and fatty acids. The human body cannot break acetone further. It is an acidic substance. It makes the cells sick and the kidneys work extra hard to eliminate acids. The appetite is lost and respiration becomes hurried. Over a period of time, the person loses weight. That is the basis of a high protein, low carbohydrate diet. It works for a short period of time but it is a different story a year or two later.

You must have noticed that in order to utilize sugar it must enter the cells first and then find its way to the mitochondria. In nature, nothing is left to a chance. The cell walls have pores, gates, binding sites, messengers, and controllers. Of these factors, Insulin is the most important member for glucose utilization. It is a hormone produced in the pancreas by Beta cells. If insulin is absent in the body or produced in less than normal amounts or the insulin is biochemically defective or antibodies against insulin making Insulin less effective. This will raise blood sugar levels in the blood. When the blood level exceeds the normal range, the condition is called Diabetes.

Normal blood sugar in the fasting state is less than 100 mg /100ml. When it exceeds 180 mg the sugar begins to show up in the urine. After a meal, depending upon the amount of carbohydrate ingested, the blood sugar may be anywhere from 100 to 180 mg/100 ml in normal individuals; in diabetics, it may be 200 mg or higher. In rare circumstances, the sugar may reach 1000 to 1200 mg /100ml.

The blood sugar may fall from having too much insulin in the body, from an insulin producing tumor or insulin administered inappropriately, or, in starvation or in conditions preventing a person from swallowing. When the level falls below 60 mg the person feels hungry, jittery, and tense and begins to sweat; when the level falls below 30 mg the person becomes confused and may behave in bizarre ways. In extreme cases of low sugar (hypoglycemia) unconsciousness, coma and death may follow.

Another hormone called Glucagon is produced by the alpha cells of the pancreas. Glucagon breaks down liver Glycogen into blood sugar and raises sugar levels.   Steroid hormones and adrenaline from adrenal glands are released in response to hypoglycemia and counteract some of these symptoms.

 

Normal blood sugar in an individual requires a balance between several hormones, insulin, food and a healthy gastrointestinal tract. In a diabetic individual, in addition to these, the level of physical activity is important also.

 

edited 2020. 

 

 

Calcium and Bone

Calcium and Bone

PKGhatak,MD

There is so much information and misinformation about Calcium and a bone disease called Osteoporosis that if by some misfortune you are diagnosed with this condition you will not know how to cope. Of course, you will follow your doctor’s advice but does your doctor really believe taking a calcium supplement and commonly prescribed medications will actually reverse the disease?

 

Here is the answer.

The rate of bone growth is highest in the teenage years. Outdoor games, physical activities and enough milk and cheese in food help to lay down a solid foundation for a healthy bonny structure. The absence of any of two essentials, - vigorous physical activities and adequate calcium with vitamin D in the diet, will produce a weaker foundation and bones will be susceptible to osteoporosis if your adult life is like an average person.

The inner structure of the bone is called the matrix. It is like a mesh, made up of protein, on which calcium is laid down by a type of bone cell called Osteoblast. Like the rest of the body, bone is a living tissue. It undergoes wear and tear and rebuilding and remodeling. Calcium needs to bind onto protein scaffolding to remain in place and provide strength and stability to the bone. Once we cross the early 20s, we are not really growing, we are just maintaining our structure. 

There is an intricate relationship between the health of bones and hormones- namely growth hormone, sex hormones, and thyroid hormone and corticosteroid hormones. In addition, a calcium regulating hormone called Parathormone plays an important role in removing calcium from bones and helps to remodel. Vitamin D and Parathormone work in opposite ways in this regard. The acid produced in the stomach, a healthy small bowel and normal kidneys are closely linked in regulating calcium like a well-choreographed soccer game as if calcium is the ball, the bone matrix the playing field, vitamin D the referee, thyroid hormone and parathormone are line judges, other hormones the coaches and team officials.

 

All these are nice to know now but it is too late to reverse the osteoporotic bones to normal healthy bones. The clock cannot be turned back; the sticking part is the protein matrix. Once it is finished laying the foundation it is done, only the female sex hormone- estrogen helps restore its vigor to the extent that new calcium will bind to it.

 

Regular physical exercise, a well-balanced meal with adequate calcium and vitamin D will go a long way to keep your bone in shape as long as you maintain your interest in exercise. Just because calcium and vitamin D help to restore calcium in the blood, it does not mean taking mega doses of these will undo the damage in osteoporosis, in fact, may damage your kidneys. Common antacids and other stronger- longer acting acid suppressing drugs prevent calcium absorption even when an adequate amount of calcium is present in the food. Soft drinks and excess alcohol interfere with calcium absorption. Certain drugs, used in the treatment of epilepsy, diabetes, and rheumatoid arthritis, etc., weaken bones.

Medications prescribed for the treatment of osteoporosis have significant adverse side effects. You have to question your doctor or the pharmacist before starting medication.

Preventing osteoporosis is a job that must start in childhood. Osteoporosis is a chronic disabling condition and is preventable.

 

edited 2020.

Know your Blood Pressure

Know your Blood Pressure

PKGhatak,MD

If you have normal blood pressure and you are middle-aged or older you have a good chance of living well beyond the lifespan of an average person. It is therefore important to know your blood pressure. You should have your Blood Pressure (BP) checked whenever you visit your doctor or a pharmacy. If your BP is normal then check it again in a year or two. BP tends to go up with increasing age, so you do not want to be surprised at a later date when someone tells you –“your BP is high.”

A BP of 110/ 70 mmHg is considered normal pressure irrespective of age – children and pregnant women excluded. Most medical practitioners will call you Hypertensive if your BP is 140/ 90. By the time the pressure rises from 110 / 70 to 140 / 90 many adverse things have taken place in the arteries and the wall of the heart. These changes are still reversible but require lifelong commitments to diet, exercise and lifestyle changes. It is so much better not to have a high BP than to deal with the consequences of hypertension.

The heart is a muscular organ and functions as a circulatory pump. As the blood is pushed out of the heart in the main vessels (Aorta) the pressure of outgoing blood must overcome the resistance of the empty blood vessels in order to flow forward. That pressure at the point of the onward journey of the blood is the first number of the BP reading say 110 mmHg of a BP of 110 / 70. It is called Systolic BP. The elasticity of the wall of the aorta helps to accommodate blood and generates a wave that spreads along the rest of the vessels (Arteries). That wave felt at the wrist is the Pulse. The blood follows the pulse wave in its outward journey. As soon as the heart stops pumping blood the pressure begins to fall. That point on the scale of the decreasing pressure, determined by listening over the artery, is known as the Diastolic BP, here 70 mmHg of a BP of 110 / 70.

A healthy heart beats 72 times every minute. So, each heartbeat lasts only 0.08 seconds (60/70=. 08). Of the 0.08 seconds, the heart pumps 0.03 seconds and relaxes and receives blood from the rest of the body for 0.05 seconds. As a result, the BP fluctuates up and down 72 times a minute as the heart pumps and relaxes. This is the reason two numbers are given in a BP reading; one at the point of maximum pressure called the Systolic BP and the other as the resting pressure known as the Diastolic BP.

Often you wondered which of the two numbers is more important. The systolic BP is a measure of the pumping function of the heart. A failing heart is unable to raise systolic BP, as seen in heart failure and in shock. Diastolic BP is the resistance generated by the walls of the blood vessels. As the elasticity of the blood vessels decreases with advancing age and from the hardening of arteries (atherosclerosis) the diastolic BP rises. In order to pump blood out into circulation, the heart must overcome the resistive pressure by increasing its systolic BP. That produces a strain on the muscles of the heart wall and in the course of time, the muscles thicken and use up more oxygen to do the same work. You must be aware that coronary blood vessels supply the heart muscles with blood, oxygen, and other nutrients. These coronary vessels are pinched as the heart wall thickens and ultimately damages the coronary blood vessels. So, both numbers are important.

Any stress or anxiety can raise the BP but these are temporary causes. Even if one has persistent stress the BP should not be allowed to reach 140 / 90.
Kidney diseases and hormonal imbalances can cause hypertension. The exact cause of hypertension remains unknown in the vast majority of cases. In medicine, if the cause of a disease is unknown it is called Essential and hence elevated BP is called Essential Hypertension. 

Blood Pressure measuring instruments are simple machines. A cuff, made of non-stretchable linen that goes around the arm, has a smaller rectangular rubber bag inside with two tubes attached to it. The end of the short tube is attached to a pressure gauge. The longer tube has a rubber bulb at the end. The rubber bulb has a one-way valve at one end and a release valve near the other end. The cuffs come as small, standard and large sizes. It is important to wrap the cuff around the arm of the person suitable for his size and to place the rubber bag squarely over the artery of the arm. One should easily find the artery by feeling the pulse on the inner side of the arm just above the elbow joint.
The person having his BP taken may be seated or lying on the examination table. The arm of the person should be brought to the level of his heart and kept there. The cuff is then wrapped correctly around the arm, the examiner should feel the pulse with his fingers placed over an artery at the elbow joint. Then squeeze the bulb and raise the pressure to 200 mm Hg. The examiner should note that the pulse is obliterated at this point; if not, he should raise the pressure further and make sure the pulse is cut off. Then release the cuff pressure slowly turning the release valve. As the pressure is lowered the pulse will return and the pressure is read off the pressure gaze. That pressure is systolic pressure. At this point release the pressure completely. And then repeat the process; this time, however, he should place the Bell End of the stethoscope over the artery at the elbow joint and listen for sounds. When the pressure is high enough to cut off the pulse there should be no sound. A" thud" like sound will return as the pressure is lowered. The pressure reading obtained by listening should be almost the same as obtained by feeling a pulse, if not, the reading detected by the pulse is the correct systolic pressure.
The diastolic pressure is detected by sounds only. As the pressure is lowered by turning the release valve the sound at the elbow becomes louder and louder, then suddenly sounds become muffled and then disappear completely. The point at the sound becomes inaudible is the diastolic pressure. There are cases where sound continues to be heard even with pressure at zero, in such cases the point where sounds transit from audible to muffle is noted. This is the diastolic BP
Measuring BP appears a simple task but like many other situations, an accurate reading depends upon the experience of the person.
A careful doctor will take your BP on both left and right arms, and then ask you to stand up and record BP again. There are various reasons for that. Abnormalities of the aorta, effects of certain medications and disease processes can cause alteration of the BP from one side to the other or by a change of posture.
If your primary reason for going to a doctor is checking your BP and the doctor is not checking your pressure himself and delegated that task to his newly hired office assistant, then you are not getting your money’s worth. You may as well buy a digital-readout BP instrument and begin monitoring your own pressure at home. However, you must know these BP instruments are not as accurate as the one described above. But once you have found out how good or bad your instrument is then you can easily correct the instrument readings.

 

revised 2020.