Sunday, March 14, 2010



  1. Skin

    • Skin color is deep brown, evenly distributed; light colors of the skin are found in palms and nails.

    • Skin is relatively dry through the body with minimal amount of perspiration on axilla and scalp.

    • Skin texture is rough.

    • Poor skin turgor, skin slowly returns to its original shape after squeezed.

    • Skin temperature is relatively warm through out the body.

    • Skin lesions noted on face and on feet. 6 moles noted on face, dark brown in color, size vary from small to large, distribution is discrete, individual moles are separate and distinct. Callus noted on right and left ankle of the feet. Edema noted on left arm.

  2. Hair

    • Hair in the body is evenly distributed, texture is fine and short and black in color. Hair in axilla is curly, about 1 inch in length, and thick.

    • Hair in head is short about 2 inch long, thin, unevenly distributed, patchy hair loss noted, black with grey in color, shiny and smooth.

    • Small like perspiration noted.

  3. Scalp

    • No dandruff noted

    • No lesions noted

    • Moist and oily

  4. Head

    • Head is normocephalic and symmetrical

    • Head is positioned to midline and has an oral contour

    • No masses noted

    • Temporal pulse rate is 103 b/m, amplitude of pulse is normal, pulse rhythm is regular

  5. Face

    • Color is brown

    • Presence of wrinkles especially on forehead

    • Capable of facial movements like elevation of eyebrows, lowering of eyebrows, closing of eyes, able to smile grin and frown, facial movements symmetrical.

    • Mustache noted; length is about 1 cm, color is black with grey and is thick.

    • Lesions noted on face and on feet. 6 moles noted on face, dark brown in color, size vary from small to large, distribution is discrete, individual moles are separate and distinct.

  6. Eyes

    • Hair in eyebrow are thick evenly distributed; eyebrow are symmetrical and of equal movements

    • Eyelashes are equally distributed and are straight

    • Eyelids closes symmetrically, drooping upper eyelid

    • Sclera is yellowish in color

    • Iris is round, cloudy and slightly bluish in color

    • No redness noted, no edema noted, no inflammation, no lesion noted

    • Good visual acuity

  7. Nose

    • Nasal septum positioned in midline

    • Nose is symmetrical

    • Color of nose is brown

    • No deformity noted

    • No tenderness noted upon palpation

    • Evenly distributed ciliary hairs

    • Discharges noted; thick, whitish

    • Flaring noted

    • Air movement in and out is obstructed

  8. Mouth and Pharynx

    • Lips is dark pink in color

    • Dry lips

    • Ability to purse lips

    • Mouth is symmetrical aligned to pharynx

    • Lips is symmetric

    • Tongue moves freely

    • Tongue in midline

    • Teeth color is dirty white

    • Soft and hard palate is pink

    • Poor gag reflex

    • Plague and tartar is present

    • Incomplete dentilation

    • Smooth and soft, no nodules, no lesions

  9. Neck

    • Carotid vein is visible

    • Wrinkles noted

    • Difficulty to flex

    • No enlargement of thyroid glands

    • Trachea in midline

    • No masses and nodules noted

  10. Ears

    • Dark brown in color

    • Tenderness and masses not noted

    • Symmetrical

    • Hair follicles noted

    • Pinna recoils back

    • Cerumen noted

    • Good hearing acuity

    • Ears firm and no tender

    • Hears normal voice tones

  11. Chest and Thorax

    • Poor skin turgor

    • No masses noted

    • Decreased respiratory excursion

    • Barrel chest

    • Adventitious breath sounds noted

    • Chest is symmetrical

    • Dullness on the ribs

  12. Breast

    • No discharges noted

    • Areola dark in color

    • Lymph nodes not palpable

    • Nipple everted

  13. Abdomen

    • Hyperactive bowel sounds

    • No pain upon percussion

    • No tenderness noted

    • Absence of scars

    • Umbilicus in midline position

  14. Upper and lower extremities

    • Skin is brown in color

    • Symmetrical

    • Skin is dry

    • Nails untrimmed, dirty and clubbing

    • Good capillary refill, 2 seconds

    • Complete digits

    • Muscle grade 2/5

    • Edema noted

    • Lesions noted, callus noted

  15. Genitalia

    • Scant amount of hair present

    • Penile skin intact

    • Penis smooth and is semi-formed

    • Present loose scrotal skin and is darker in color than the rest of the body

    • Scrotum is symmetric


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