General appearance
Thai woman is teenage , slender, alert ,interactive, to cooperate
Biology and Physical measurement
High 158 cm, weight 51 kg , Normal vital sign ; Temperature 36.5 C, Pulse rate 82 beat/min, Respiratory rate 20 beat/min , Blood pressure 110/70 mmHg
1. Skin
skin white color, normal distribution of hair , smooth texture , no lesion , normal moisture, warm temperature, good skin turgor, edema: no localize and generalize, nail normal shape, normal size and normal angle 160 C
2. Head
Hair ; dyeing hair brown color , normal distribution of hair, soft texture
Scalp ; no lesion, no cyst, no lump
Skull ; round shape, normal size, symmetry, no mass, no tenderness
3. Face
Insp ; oval shape, symmetry, white color, no lesion
Palp ; Temporal, Masseter, Pterygoid M; no mass, no tenderness, trigeminal N 5 normal
ROM, MS ; trigeminal N 5 normal
Temperomandibular joint ; trigeminal N5 normal
Insp; test facial N ; normal motor function and fecial N7
Test sensation touch and pain ; normal trigeminal N5
4. Ear
Insp ; External configuration, no mass , no tenderness
Ear canal ; no cerumen, no discharge, normal eardendrum
Palp; Tragus ; no tenderness, no otitis externa
Mastiod ; no tenderness, no otitis media
Test auditory N ; normal hearing and normal auditory N8
5. Eye
External configuration ; no herniated fat, no periorbital edema
Eye brow ; symmetry, no tattoo, no scaliness
Eye lid ; no ectropion, no entropion, no lid retraction
Lacrimal gl and Lacrimal sac ; no discharge, no tear, no swelling, no tenderness
Conjunctiva and sclera ; no pale, no cyst, no inflame and white sclera
Pupil ; normal size, normal shape and symmetry
Reaction to light ; Direct and consensual reaction ; pupil reaction to light from 3mm to 2 mm both eyes, normal Optic N3 and normal Oculomotor N3
Eye movement ; normal oculomotor N3 , normal trochlear N4, normal abducens N6
Eye convergence ; normal optic N2, normal oculomotor N3
Visual field and Visual acuity ; normal optic N2
6. Nose
Ext configuration ; normal shape, symmetry
Nasal canal ; discharge clear, pink mucosa, septum no deviation and perforation, turbinate no polyps and ulcer
Sinus palp ; frontal and maxillary sinus no tenderness
Sense of smell ; normal olfactory N1
7. Mouth and Throat
Lips ; pink color, moisture, no lesion, no ulcer
Buccal mucosa ; pink color, no pale
Palate ; no Thrush, no Kaposi’s sarcoma
Gum; no swelling, no scurvy
Teeth ; no dental caries, no tooth loss
Tongue ; normal size, pink color ,smooth texture, no lesion, normal movement,
normal hypoglossal N12
Tonsils and Pharynx ; no enlargement, pink color, no ulcer
Palate and Uvula ; midline, normal vagus N10
Gag Reflex ; normal glossopharyngeal N9 and normal vagus N10
Taste; normal facial N7
8. Neck
Insp ; normal shape, symmetry,no mass, no lesion, no scar
Palp ; no mass, no tenderness
Trachea ; midline
Thyroid ; anterior and posterior position normal shape and normal size, no tenderness
Lymph node ; non palpable lymph node
Sternomastoid, Trapeziuse M ; normal ROM, normal MS and normal Spinal accessory N11
9. Breast
Insp ; normal contore, no dimpling
Breast ; normal size, normal shape, no dimpling, no lesion, no imflame
Nipple ; no retraction, no discharge, no inversion
Palp breast and Nipple ; no mass and tenderness
Palp Axillary lymph node; non palpable axillary lymph node
10. Shoulder and Hand
Insp ; normal shape, no lesion
Palp ; shoulder, elbow, wrist and fingers : no mass, no tenderness, no crepitation
ROM ; normal ROM of shoulder, elbow, wrist and fingers
MS ; normal MS of shoulder, elbow, wrist and fingers
Sensation ; Touch and Pain normal sensation
Deep tendon Reflex ; normal Deep tendon Reflex glade 2+
11. Thorax and Lung
Insp ; no lesion, normal chest shape, AP diameter: lateral diameter 1:2, symmetry
Chest movement; normal chest movement
Palp ; no mass, no tenderness
Respiratory excursion ; Lung expanion symmetry
General appearance Thai woman is teenage , slender, alert ,interactive, to cooperateBiology and Physical measurementHigh 158 cm, weight 51 kg , Normal vital sign ; Temperature 36.5 C, Pulse rate 82 beat/min, Respiratory rate 20 beat/min , Blood pressure 110/70 mmHg1. Skin skin white color, normal distribution of hair , smooth texture , no lesion , normal moisture, warm temperature, good skin turgor, edema: no localize and generalize, nail normal shape, normal size and normal angle 160 C 2. Head Hair ; dyeing hair brown color , normal distribution of hair, soft texture Scalp ; no lesion, no cyst, no lump Skull ; round shape, normal size, symmetry, no mass, no tenderness3. FaceInsp ; oval shape, symmetry, white color, no lesion Palp ; Temporal, Masseter, Pterygoid M; no mass, no tenderness, trigeminal N 5 normal ROM, MS ; trigeminal N 5 normal Temperomandibular joint ; trigeminal N5 normal Insp; test facial N ; normal motor function and fecial N7 Test sensation touch and pain ; normal trigeminal N54. EarInsp ; External configuration, no mass , no tenderness Ear canal ; no cerumen, no discharge, normal eardendrum Palp; Tragus ; no tenderness, no otitis externa Mastiod ; no tenderness, no otitis media Test auditory N ; normal hearing and normal auditory N85. Eye External configuration ; no herniated fat, no periorbital edema Eye brow ; symmetry, no tattoo, no scaliness Eye lid ; no ectropion, no entropion, no lid retraction Lacrimal gl and Lacrimal sac ; no discharge, no tear, no swelling, no tenderness
Conjunctiva and sclera ; no pale, no cyst, no inflame and white sclera
Pupil ; normal size, normal shape and symmetry
Reaction to light ; Direct and consensual reaction ; pupil reaction to light from 3mm to 2 mm both eyes, normal Optic N3 and normal Oculomotor N3
Eye movement ; normal oculomotor N3 , normal trochlear N4, normal abducens N6
Eye convergence ; normal optic N2, normal oculomotor N3
Visual field and Visual acuity ; normal optic N2
6. Nose
Ext configuration ; normal shape, symmetry
Nasal canal ; discharge clear, pink mucosa, septum no deviation and perforation, turbinate no polyps and ulcer
Sinus palp ; frontal and maxillary sinus no tenderness
Sense of smell ; normal olfactory N1
7. Mouth and Throat
Lips ; pink color, moisture, no lesion, no ulcer
Buccal mucosa ; pink color, no pale
Palate ; no Thrush, no Kaposi’s sarcoma
Gum; no swelling, no scurvy
Teeth ; no dental caries, no tooth loss
Tongue ; normal size, pink color ,smooth texture, no lesion, normal movement,
normal hypoglossal N12
Tonsils and Pharynx ; no enlargement, pink color, no ulcer
Palate and Uvula ; midline, normal vagus N10
Gag Reflex ; normal glossopharyngeal N9 and normal vagus N10
Taste; normal facial N7
8. Neck
Insp ; normal shape, symmetry,no mass, no lesion, no scar
Palp ; no mass, no tenderness
Trachea ; midline
Thyroid ; anterior and posterior position normal shape and normal size, no tenderness
Lymph node ; non palpable lymph node
Sternomastoid, Trapeziuse M ; normal ROM, normal MS and normal Spinal accessory N11
9. Breast
Insp ; normal contore, no dimpling
Breast ; normal size, normal shape, no dimpling, no lesion, no imflame
Nipple ; no retraction, no discharge, no inversion
Palp breast and Nipple ; no mass and tenderness
Palp Axillary lymph node; non palpable axillary lymph node
10. Shoulder and Hand
Insp ; normal shape, no lesion
Palp ; shoulder, elbow, wrist and fingers : no mass, no tenderness, no crepitation
ROM ; normal ROM of shoulder, elbow, wrist and fingers
MS ; normal MS of shoulder, elbow, wrist and fingers
Sensation ; Touch and Pain normal sensation
Deep tendon Reflex ; normal Deep tendon Reflex glade 2+
11. Thorax and Lung
Insp ; no lesion, normal chest shape, AP diameter: lateral diameter 1:2, symmetry
Chest movement; normal chest movement
Palp ; no mass, no tenderness
Respiratory excursion ; Lung expanion symmetry
การแปล กรุณารอสักครู่..
