การประเมินสุขภาพ:ใบงานชิ้นที่ ๑ แปลข้อมูลการตรวจร่างกาย

Physical examination

Name : O Miss O Mrs. O Mr. .......................................Sirname...................................No….....Class........

General  appearance  (2 คะแนน)

Thai male (female), look well (eg. ill, weak, not in acute distress, in pain).

Thin (eg. fat, or sthenic, hyposthenic, hypersthenic built). Normal growth and development.

Skin  (2 คะแนน)

Normal color for race , smooth texture, warm to touch, good  skin turgor, moisture, no edema, no cyanosis, and jaundice.  No lesion (eg. petechiae, ecchymosis, rash).

Head and  Face  (1 คะแนน)

Symmetry, normal shape, no mass and lesions.

Hair / Scalp  (2 คะแนน)

Black color, normal distribution (eg. hirsutism, alopecia), no white streak, nits and pediculus. Scalp dry, no lesion.

Ears  (2 คะแนน)

External ears no  mass, no lesion, both  ears  canal  normal, no abrasion or inflammation, tympanic  membrane intact. A lot of yellow-brown ear wax. Normal hearing.

Eyes  (3 คะแนน)

Normal  eyes contour (eg. slightly exophthalmoses), no edema, conjunctiva not pale.  Sclera no jaundice  and  no injection. Pupils round 2 m.m. reaction to light both eyes.  No pterygium  (eg. cataract, uveitis, strabismus). Fundi normal, no papilledema.

Nose  (2 คะแนน)

External configuration normal, mucous membrane pink. Turbinate not enlarged, not injected, no discharge. Septum not deviated.

Mouth  (3 คะแนน)

Buccal  mucous membrane  pink, opening  salivary  gland  normal, no  dental caries. Lips  not pale, no cyanosis. Oropharyx  not  injected. Uvula in midline.Soft palate and hard palate no  lesion. Tonsils not enlarged, not injected.

Lymph nodes  (3 คะแนน)

Submandibular lymph node (eg. pre-post-auricular, occipital, cervical-anterior and posterior triangles, supraclavicular, axillary, epitrochlear, inguinal, and femoral) 1 cm.  consistency, movable (eg. fixation), not tender, others  not  enlarge.

Neck (2 คะแนน)

No stiffness of  neck.  Trachea  in  midline (eg. deviated to the left or right).  Thyroid gland slightly enlarged ~ 35 gm., moved on swallowing, no bruit. No engorgement of neck vein.

Breast  (1 คะแนน)

Symmetrical breast size, no discharge or mass.  

Chest; Thorax and lungs  (7 คะแนน)

Normal chest contour (eg. barrel-shape).  A-P diameter: Lateral  diameter = 1:2.  Lungs good expansion, equally, no retraction. Percussion hyperresonant (eg.resonant, dull, flat). Normal breath sound (eg. vesicular, bronchial, bronchovesicular) or diminished, etc. No adventitious sound (eg. fine or coarse crackles/crepitation, rhonchi, wheezing, pleural friction rub, etc). Tactile fremitus resonance, equally. No kyphosis, lordosis and scoliosis lumbar. 

Cardiovascular; Heart and peripheral vascular (3 คะแนน)

No active pre–cordial, no  bulging, no thrill, no heaving.  H.R. 110 /min., normal rhythm. PMI  at 5^th  ICS, MCL. S1S2 normal, no murmur (eg. murmur grade 1-6/6), no gallop, no pericardial rub.  Peripheral pulses normal rhythm and equal forcefully. (eg. radial, popliteal, dorsalis pedis, posterior tibial pulses). 

Abdomen  (7 คะแนน)

Normal abdominal contour, no distension, no bulging, no superficial vein dilatation, no surgical scar.  Percussion tympanic sound (eg. hypertympanic, dull).  Liver and spleen can’t be palpable [eg. liver 2 finger-breadths, sharp edge, smooth surface, firm consistency, not tender, spleen 2 finger-breadths], no abdominal  mass. [eg. mass 2×3 cm. in diameter, well defined, smooth surface, hard consistency, movable] Bowel sound  +ve, 4-6 /min.  No tenderness, rebound tenderness, guarding and rigidity.  No fluid thrill.

Neurologic  (8 คะแนน)

Mental status: Good  consciousness (eg. Oriented  to place, time  and  person). 

Motor system: Normal tone.  Motor  power  grade 5 (grade 0-5/5), equally, normal  gait  and  posture.  No fibrillation, no fasciculation, no atrophy.

Sensory system: No sensation   impairment, intact in all area (pain, light, touch, vibration, position and sterognosis)

Deep tendon reflex (DTR) (eg. biceps, triceps, supinator, knee, ankle) + 2 all.  Superficial reflex (eg. abdominal, cremasteric) positive.  [if newborn; primitive reflex (eg. sucking, grasp) positive]  Plantar response : flexor or extensor.

Meningeal irritation : Normal. (eg. stiffness of neck, Kernig sign, Brudzinski sign)

Extremities  (2 คะแนน)

Normal movement, no deformity, no cyanosis, no flapping tremor. Skin good turgor, no lesion.

No edema (eg. pitting edema) and palpable node.

Genitalia

Not done

Rectal

Not done