An elderly Thai male, 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 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 deformity, no pretibial
pitting edema, no petechiae or ecchymoses
Right Calf
No tenderness, no
hematoma
Gap 1.5 cm at
Tendon of Achilles (palpable depression on the tendon)
Thompson’s Squeeze
Test positive
Normal passive
range of motion on right ankle joint but limited active range of motion
Patient is
incapable of performing a single heel-raise
Others
Within normal limit
No crepitation, no
edema, no tenderness
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
