Skin: white in color, skin surface not pale, warm to touch , excessive moisture, smoothness, normal skin turgor, no pitting edema, no vascular or bleeding lesions, no rash
Nails: Pink in color, normal shape.
Hair: Black and short hair, normal distribution.
Head: Symmetrical, normal shape and size, no scar no lesion , no tenderness.
Face: Symmetrical, appropriate facial expression, no muscle weakness , no deformities, touch intact, no tenderness at both sinuses frontal and maxillary sinus.
Eyes: Eyebrows and eyelashes present and normal distribution, normal eyelids, no ptosis, normal lacrimal apparatus, conjunctiva not pale , no ecteric sclera , pupils react to right 2 mm. both eyes , normal extraocular movement no nystagmus or strabismus
Ears: Mastoid no tenderness or swelling, no mass or lesion auricles and canals , no discharge, but contains some dark brownish wax along its wall, both tympanic membranes intact and normal color, no perforation, light reflex present, good hearing.
Nose: Symmetrical, no deformity, rhinorrhea and swelling mucosa , normal septum, good smelling.
Mouth : Lips not pale, no cracking or angular stomatitis, good hygiene in mouth organs , tongue pink not pale , smooth surface , no thrush and no tong tide , gum no inflammatio or bleeding and no dental caries
Throat : pharynx mild inject, no lesion, tonsils not enlarged , uvula rises in midline on pronation, gag reflex present.
Neck: Trachea no deviation, carotid pulsations equal and good quality, no neck vein engorged, thyroid gland not palpable, cervical lympnode not palpable.
Chest and Lung : Symmetrical, normal contour, no deformity or fracture of ribs, chest wall movement Rt.=Lt., tachypnea, no abnormal retraction and bulging in intercostal space, no tenderness, no mass.
Lung expand no retraction , Respiratory rate 66 / min หน้าอกไม่บุ๋ม Crepitation breath sound at right upper lobe .Resonanc percustion
Heart : No cardiac thrill, apical impulse at MCL. Lt. 5th ICS, no heave, heart rate 120/min, regular, no murmur or gallop.
Breasts : Symmetrical, normal nipple, no masses or tenderness
Abdomen: Flat, no distention, no visible peristalsis , no dilated veins, no pulsation umbilicus, no surgical scar, normal bowel sound, normal abdominal tympany, no shifting dullness, no fluid thrill, , no guarding no rigidity, no tenderness, no mass , spleen and liver not palpable
Back : no scar , no rash , no lesion , no mass , no tenderness , no deformities of spine .
Musculoskeletal : Arms and legs symmetrical, no deformity, normal movement, muscle strength, muscle power grade 5, no edema or swelling of joint.
Neurological: Consciousness alert and responsive, appropriate behavior , sensory intact, Stiff of neck and kernig sign negative , Babinski sign absent , motor system no atrophy or tremor, no weakness.