Physical Examination
 

History
Physical Examination
Discussion
Management

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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

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 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

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

Reflexes

deep tendon reflex

Barbinski sign

clonus

Romberg s sign

2+ all

plantar

negative

negative

 

  ʶ ҹ

 

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Ѻاش 15/06/2010

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