V/S: T=37.4 °C P=82 bpm R=20 bpm BP=130/80 mmHg
GA: Thai old male,fat,normal posture,normal gait,good conscious,good mentally,good cooperated.
Skin: good skin turgor,no ecchymosis,no petechiae,no spider nevi,no jaundice.
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,pupil 2 mm.react to light symmetry both eyes.
Ears: external ear no mass or lesion,ear canal no abrasion or inflammtation or tenderness,tympanic membrane intract.
Nose: no discharge,mucous membrane pink not injected,turbinate pink,septum not deviated.
Mouth and Throat: lip dry,not pale,no cyanosis,pharynx not injected,tonsil not enlarge,uvula midline.
Neck: trachea not deviated,thyroid not enlarged,neck vein not engorged,movement no limitation or stiff neck.
Lymph node: pre-auricular,post-auricular,occipital,cervical,supraclavicular,axilary,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, normal breathing, no adventitious sound.
Heart: point of maximum impulse (PMI) at 5th ICS and MCL, heart rate 82 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 no 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) 70° refer pain, babinski’s sign negative.