An elderly Thai
female, good consciousness, no pallor, no jaundice, no cyanosis, no dyspnea,
no pitting edema, good consciousness, well cooperated
Skin
No petechial
hemorrhage or ecchymoses, no abnormal pigmentation, no rash, normal skin
turgor
Head
No evidence of head
trauma, symmetry, normal facial expression
Eyes
No pale
conjunctivae, no icteric sclerae, no ptosis, no strabismus
Visual acuity
Right
20/50-1 20/40
Left
20/400 20/100-1
Orbit
Symmetry, no
crepitus, no abnormal mass
Motility
Normal conjugate
eye movement, normal convergence, normal Hirschberg’s 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
Conjunctivae
No conjunctival
injection, no chemosis, no pinguecula or pterygium, no subconjunctival
hemorrhage, no tear of conjunctiva
Cornea
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
Iris
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
Lens
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
IOP
Right
11 mmHg
Left
14 mmHg
Color Vision
Not be examined
Ears, Nose, Throat
no oral thrush, no
injected pharynx, no enlarged tonsil gland
Neck
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
Abdomen
Soft, no
tenderness, no distension, normal bowel sound, no palpable liver or spleen
Extremities
No deformities, no
pretibial pitting edema, no petechiae or ecchymoses
Neuropsychiatric
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
