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Description

Post A

This volunteer is a 30 year old Caucasian male, who was born and raised in Clearwater Florida. The patient is healthy with no past medical history. The patient reports no chronic or acute pain, no surgeries, injuries or infections.

The skin color is white, it is uniformed, there is no present rash, lesions, cuts or scrapes. The skin is smooth and warm to touch. There is no tenting or turgor (SPC, n.d.).

The hair is black and evenly distributed. It is clean and neat. The hair texture is smooth and soft.

The nails are white, there is not present cracking or ridges. There is no clubbing and capillary refill is less than 3 seconds.

The face is clean, symmetric and round. There are no tics or lice present. There are no pigmentation variations (SPC, n.d.) .

The head is round and symmetric. There is no tenderness over the frontal and maxillary sinuses (SPC, n.d.) .

The temporal arteries were palpated. There were no thickening. There is positive movement of the hyoid bone and cartilages with swallowing. There is no popping or audible sounds when assessing the temporomandibular joint. The trigeminal nerve is positive for sensation. The masseter muscle is felt with chewing (SPC, n.d.) .

The neck is symmetric in shape. There is no jugular venous distention. The trachea is mid line to the neck. There is no present tracheal tug or abnormal pulsation felt. The left thyroid was felt with swallowing and the right thyroid was felt with swallowing. There is no enlargement of nodules felt. The 9 sets of lymph nodes were palpated. There are no tender or swollen nodes. The spinal accessary nerves were assessed, there was positive range of motion. Patient preformed neck rotation and shoulder shrug with and without resistance. There were no abnormalities (SPC, n.d.) .

At this point there were no abnormalities with this patient. The patient is a young healthy male and does not have any potential risk for any health related issues at this time.

St. Petersburg College. (n.d.).

Head, face and neck exam with explanation.

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Post B

Client is a 60 year on male born in Bradenton, Fl. His race is African American. Ethnicity is American.

Health history findings

Skin:

The client reports he occasionally has an area on the mid lower back that itches. The area usually itches after taking a shower.

He reports there is not a noticeable rash that he can see, he knows it just itches. The client has his wife to rub the area so he will not scratch the area with his fingernails.

He reports a skin tag on his waistline on the left side. At one time he had two skin tags removed from waistline and upper back. The skin tags were removed by freezing them off by his physician during a routine office visit.

He reports daily showers in lukewarm water.

He reports the only time he really gets out in the direct sunlight is when he is doing lawn work. He protects his skin by wearing a hat, long sleeve shirt and long pants.

Hair:

He reports his hair is starting to grey and it is drier than it use to be. He does not use any hair dye.

Nails:

He reports he has never had any type of fungal infection to his fingernails.

Head/face:

The client head is appropriate for the size of his body. The client facial expressions are symmetrical without any involuntary movements.

Neck:

The client has no neck vein distention or trachea deviation. There was no enlargement of the thyroid or lymph nodes.

He denies any other acute changes to his skin after having the skin tags removed. He only complains about having a dry scalp at times. He has no complaints regarding his fingernails.

Family history:

He does not report any family history of skin impairments.

Physical exam findings

Skin:

Skin is light brown. Skin color is consistent with the race and ethnicity of this individual. There are no noticeable wounds are markings on this clients skin. His skin is warm, clean and intact and tenting is not present.

Hair:

Hair on the head on the client is clean without any odor. The hair is evenly distributed without thinning. Scalp is dry without any flakiness observed.

Nails:

All nails are present, clean and evenly trimmed. There are no ridges or curves to the nails. The nail beds are pink in color with immediate capillary refill.

Analysis:

There were no abnormalities reported in the history of the client. The client is not at risk for any skin abnormalities from the sun due to his limited exposure to the sun.

  
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