Physical Examination

Physical Examination

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Physical Examination

Vital Signs

Body Temperature                36.6                      OC

Pulse Rate                             80                    /min

Respiratory Rate                    18                    /min

Blood Pressure                     130/80            mmHg

General Appearance

An elderly Thai female, good consciousness, no pallor, no jaundice, no cyanosis, no dyspnea, no pitting edema, good consciousness, well cooperated


No petechial hemorrhage or ecchymoses, no abnormal pigmentation, no rash, normal skin turgor


No evidence of head trauma, symmetry, normal facial expression


No pale conjunctivae, no icteric sclerae, no ptosis, no strabismus

Visual acuity

Right   20/50-1                        20/40

Left      20/400            20/100-1


Symmetry, no crepitus, no abnormal mass


Normal conjugate eye movement, normal convergence, normal Hirschbergs test and cover test, no nystagmus, no strabismus

Lid and Lash

No ptosis, no lid retraction, no abnormal skin lesion, normal eye lashes, no swelling of eye lid, no exophthalmos or enopthalmos or lagophthalmos


No conjunctival injection, no chemosis, no pinguecula or pterygium, no subconjunctival hemorrhage, no tear of conjunctiva


Clear, no keratitis, no corneal abrasion or ulcer, no edema, no ruptured cornea, no foreign body, no leukoma

Anterior chamber

Deep and quiet, clear, no hypopyon, no hyphema, no keratic precipitate


3 mm normally reactive to light both eyes both in direct and consensual pupillary light reflex, no iritis, no iridodonesis, no coloboma, no synechiae, no relative afferent pupillary defect


Right   no cataract, pseudophakia (intraocular lens)

Left      opaqueness in the central area (grade 2+)


Ophthalmoscopic examination

Right  normal corneal red reflex, normal disc, cup-disk ratio <0.3, no neovascularization of disc, normal A-V ratio (2:3), no vascular occlusion, no microaneurysm, no neovascularization elsewhere, normal macular reflex, no exudate, no hemorrhagic lesion

Left      poor corneal red reflex, not-visible eye ground


Visual Field

Normal visual field on confrontation test bote eyes



Right   11 mmHg

Left      14 mmHg


Color Vision

Not be examined

Ears, Nose, Throat

no oral thrush, no injected pharynx, no enlarged tonsil gland


Normal position of trachea, no enlarged thyroid gland, no abnormal mass, no stiffness of neck, no neck vein engorgement

Lymph Node

No palpable lymph node

Respiratory System

Normal chest movement and expansion, no tachypnea, normal tactile fremitus and vocal resonance, normal & equal breath sound, no adventitious sound

Cardiovascular System

No tachycardia, pulse full and regular rhythm, PMI at 5th left intercostal space midclavicular line, no heaving, no thrill, normal S1, S2, no murmur


Soft, no tenderness, no distension, normal bowel sound, no palpable liver or spleen


No deformities, no pretibial pitting edema, no petechiae or ecchymoses


Mental Function

good consciousness, well cooperated and good orientation to time, place, and person

Cranial Nerves

grossly intact

Motor Function

no  tremor, normal muscular tone and power

Sensory Function

normal sensation to pain temperature, touch and proprioception


deep tendon reflex

Barbinski sign


Romberg s sign

2+ all





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