Vital Signs

Body Temperature                36.6                      ^OC

Pulse Rate                             72                    /min

Respiratory Rate                    20                    /min

Blood Pressure                     120/70            mmHg

General Appearance

An middle-age ai 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, 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 :    nasal masses both sides in middle meatus, gray collor, smooth surface

Mucosa :          pale, no swelling, no bleeding, cleary discharge both sides

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 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