Vital Signs

Body Temperature          37                  ^OC

Pulse Rate                       86            /min

Respiratory Rate             20            /min

Blood Pressure                157/76        mmHg

General Appearance

An elderly Thai widow, 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, normal visual acuity and visual field no crepitus, no abnormal mass, normal extraocular movement and symmetric both eye, no nystagmus or strabismus, no exophthalmos, no lid retraction, no conjunctival injection, no conjunctivitis, no subconjunctival hemorrhage, pupil 3 mm normally reactive to light

Ears

Auricles :        no deformity, no lump, no abnormal lesion, no tenderness

Ear Canal :    no abnormal discharge, no foreign body, no swelling, no sign of inflammation

Ear Drum :     intact, no perforation

Hearing :               Rinne’s test                AC>BC both ears

               Weber’s test      midline, no lateralization

Nose

Nose :         no deformity, symmetry

Lateral Wall :       no mass

Mucosa :    no pallor, no swelling, no bleeding, no abnormal discharge

Septum :    no deviation, no sign of inflammation, no perforation of septum, no bleeding, no polyp, no ulcer

Sinuses :    no tenderness

Mouth and Throat

Lips :         no dry lip, normal color, no lump, no ulcer

Oral mucosa :        normal color, no oral ulcer, no white patch, no nodule

Gum :         pink, no swelling, no ulcer

Roof of mouth :      normal color and architecture of the hard palate

Tongue :    normal movement, no nodule, symmetry, no ulcer

Floor of mouth :     symmetry, no nodule, no ulcer

Nasopharynx :       no mass, no posterior nasal drip, no bleeding, no pharyngeal tonsil enlargement

Oropharynx : normal position of uvula, no ulcer, no peritonsillar abscess

Hypopharynx and Larynx :  no injection, normal movement of true vocal cords, no mass at base of tongue, pyriform and vallecular

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 5^th 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 deformity, no pretibial pitting edema, no petechiae or ecchymoses

Left knee

        No redness, no warm

        Moderate swelling, effusion grade 2+,

        Mild varus deformity about 5 degree,

        Range of motion : 10⁰ / 10⁰ / 120⁰

        Moderately pain on varus stress test

Others

        Within normal limit

        No crepitation

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