Head-to-Toe Examination
Skin, Hair, Nails: I conducted a skin color, the pigment of the patient’s skin appear darker and some of the region appeared to have been exposed to the sun unevenly such as the face and the fore head. However, there was no change in the symmetry, border ad he elevation. The patient had some stretchmarks in the lower part of the abdomen. The patient’s skin was warm bilateral and there are mild symptoms of the hypertemenia on the patient. The patient’s perspiration was quite abnormal on the regions of the neck and the axilla. There were no oral mucous membrane and the patient skin was sufficiently hydrated. The texture of the skin was smooth for the better parts of the body with some regions showing some symptoms of hypothyroidism. The skins epidermis was uniformly thin for the better parts of the patient’s body with no calluses on either sole of the feet. There was no edema observed on the patient’s skin.
On pinching, the turgor of the kin was normal and the mobility very viable and in good shape. This indicated that there was a proper hydration and elasticity. There were no brushing, vascularity or traumatic kind of lesions on the skin. Therefore, there was normal distribution of the hair and a closer view of the kind revealed that there were few pest inhabiting the hair on the head. The distribution of the kin hair conforms to the normal female patterns. This together with the normal curved surface doe presets over 80 degrees. The surface feel very regular and smooth without any element of splitting. The thickness of the hair in the body as very uniform expects in the chest and the head regions. The capillary refill test that I conducted was very normal and the change in the color took less than 2 seconds.
Head, Face, and Neck, Including Regional Lymphatics: the patient had a normcephic head. Therefore were o deformities I the head, no lesion nor lumps detected. The facials structure appeared more symmetric, with symmetric eyebrows and the nasolabial folds noted on either side of the patients mouth. Some swellings and involuntary facial movement were periodically observed. The facials expression which was quite inappropriate to the mood of the patient were observed during the conversation and the examination of the face. However, the facial hair were even. There were no abnormal changes in the skin tone. I asked D.N to touch her chin to the chest and turn the head ether sides while at the same time trying to touch her shoulder and swinging the head backwards and in front.
The motion towards the back was smooth and controlled. Motion toward informant was very limited and seemed to be uncontrolled. The head was centered to the midline. The right muscle strengths and the formal cranial never XI statues was the case. No obvious pulsation experienced. I palpated the neck node of the patient, the salivary gland however were not palpable. Some abnormal enlargement were observed. The scar in the neck present from the surgical posterior cervical cancerous nodes. The patient’s thyroids was not palpable and moves up and down during the process of swallowing anything.
Eyes: after the Snellen eye chart test on the patient, the patient did not hesitate and was able to read smoothly own the chart and indication that she did not have any major problem of the vision. The peripheral vision field were very good. The bilateral systematic Cornea reflect were presets and the eyes of the patient appeared very symmetric in shape. The eyelid closer were very normal and on extraocular muscles weakness was observed during the examination. Beside there was no Cyanosis or the pallor of the upper and the lower eyelids. The patient’s eyes did not have any lesion or scars. The sclera was efficient moist ad appeared white in color. The corer of the eye appeared clear, smooth and very opaque. The lacrmaic gland however did have some small swellings though tender. The Iris of the aye was flat with an oval regular shape and proper coloration. The PEERRELA was test conducted was very complete. There was a significant Anisocoric of the patient’s pupil. But no sign of any cataract noticed on the eye of the patient. The vessels of the eye appeared very normal.
Ears: the ear had no masses, had few systems of a healing lesion and was very tender both in the pinna d the ear auricle. The tympanic membrane of the patients her was gray and appeared intact with just a sign perforation on the lower end. A whispered voice test was carried out and the patient managed to properly repeat the words that were being whispered. This indicated that the patient’s hearing was decent and had no problem however the patient was not able to hear tone by tone conducted by the Weber test that was conducted perhaps due to the state of mind. The Renner test conducted, AC >BC was done bilaterally.
Nose: I did an inspection and palpated the exterior end of the nose. Nares are asymmetrical, there was no septal deviation in proposition with the other feature of the face. Few deformities are noticed and tenderness to palpation.
Mouth and Throat- the Muscle and the lips had no cracks. There was no gum bleed and all the tooth intact. No dark spots on the teeth and malocclusion. The young was symmetric and no tremor notices. The pharynx properly pick and not exudate.
Neck: the neck had a complete ranges of motion ROM mild tils of the head noticed. Severally hands of the patient not Palpated. The nodes feel movable in all direction soft and tender.no bruins observed during the auscultation. There was no Jugular pulse palpable at all.
Breasts and Regional Lymphatics: at the time of inspection of the patient’s breast, the best were symmetrical in sizes and shape. There is homogeneity of the breast in all aspects. Skin appeared like smooth with eve color. At that time there was no redness or lesion on the breast and the superficial veins quite dilated.
Thorax and Lungs: No signs of the Barrel in the chest, no observable due to the lack of the thick tissues on the lower level of the abdomen. Patent attained the relaxed posture when being examined. The process quite adulated in space not in a line. A consistent skin color and also consistent with the generic background. The normal patient’s breath was normal in bound and no cracks are observed. The moisture of the skin smooth and has not observable lumps. Has a short and normal inspiration and expiration during the examination
Heart and Neck Vessels: Has a normal carotid strengths was 2+no bruits experienced quite an abnormal pulsation, no distention witnessed and excretal jugular veins observed at the time of inspection. No murmurs experienced and mild systolic murmurs experienced.
Gastrointestinal: the patient’s abdomen was flat and normally symmetric. There are no abdominal distention bulges, masses and the ascites. Skin of the patient felt smooth and feels normal without any bump. Perfectly good turgor reflecting hydrating and effective nutrition
Peripheral Vascular: at the time of the patient’s examination, the color of the skin was good and in heritage with the background and no cyanosis on the skin seen. The upper extremist symmetric in shape and size.
Female Genitourinary: the external general of the patient had no notable lesion or rashes. The vaginal opening appeared as a vertical, small slit and perineum is moist.
Musculoskeletal: mental state, appearance and speech of D.N very appropriate. Remote and the patient’s recent memories are intact and effective. No coloration of the anal and there are small pigmentation.