Physical Examination
 

History
Physical Examination
Discussion
Management

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Physical Examination

Vital Signs

Body Temperature                37                        OC

Pulse Rate                             80                    /min

Respiratory Rate                    20                    /min

Blood Pressure                     130/80            mmHg

General Appearance

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 :      Rinnes test    AC>BC both ears

                      Webers 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)

            Thompsons 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

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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