GA: thai old female,normal posture, normal gait, good conscious, good mentally, good cooperated.
Skin: good skin turgor, no ecchymosis, no petechiae, no spider nevi, no jaundice, warm to touch.
Nail: normal nail, pink, no spoon nail, normal finger, no clubbing of finger, no joint deformity, normal capillary refill.
Head and Face: normal shape, normal size, no trauma scar& lesion, no dandruff, smooth hair, a little hair loss, no moon face, no butterfly rash.
Eyes: not pale conjunctiva, no icteric sclera, conjunctiva not injected, pupils 2 mm. react to light symmetry both eyes.
Ear: external ear no mass or lesion, ear canal no abrasion or inflammation or tenderness, tympanic membrane intact
Nose: no discharge, mucous membrane pink not injected, turbinate pink, septum not deviated.
Mouth and Throat: lip not dry, not pale no cyanosis, pharynx not injected, tonsils not enlarged, uvula midline.
Neck: trachea not deviated, thyroid not enlarged, neck vein not engorged, movement no limitation or stiff neck.
Breast: normal nipples no retraction, no mass, no tenderness, no discharge, symmetry both size.
Lymph nodes: pre-auricular, post-auricular, occipital, cervical, supraclavicular, axillary, inguinal lymph node not palpable.
Lung: normal shape chest, AP: transverse 5:7, no kyphosis or scoliosis or lordosis, lung expand equally, no retraction, percussion normal resonance, tachypnea, no adventitious sound.
Heart: point of maximum impulse (PMI) at 5th ICS and MCL, heart rate 112 bpm., regular rhythm, heart sound S1S2 normal; no murmur.
Abdomen: flat shape, no excision scar, no distention, soft, no guarding, no rigidity, no tenderness, no mass, liver and spleen not palpable, active bowel sound 7 bpm.CVA tenderness.
Extremities: no pitting edema, normal knee joint, no tenderness, no crepitus.
Motor power: no weekness, grade 5/5 upper and lower extremity
Nervous system: DTR 2+ at all, Straight legs raising test (SLRT) 90° no refer pain, babinski’s sign negative.