Skin/Hair/Nails and Head/Face/Neck Documentation Obtain the following

Skin/Hair/Nails and Head/Face/Neck Documentation Obtain the following information on an adult volunteer. For the history, ask about the items indicated. For the physical exam items, read the assigned chapters, review the course presentations/videos, and gather needed equipment before performing the exam. Use this guide when documenting the findings. Be sure to address all items in your documentation. Volunteer Information Gender, age, birthplace, race/ethnicity Health History Findings (address each item and list specific denials) Skin, hair, nails, head/face, neck • Past medical history – Personal history of acute/chronic disease, surgery, injury, infection, pain • Review of systems o Skin – Lesions, dryness, pallor, color, change, moles/changes, easy bruising, unusual odor, sun exposure, sun protection o Hair – Loss, change in texture, itching, hair dye o Nails – Natural or acrylic nails, change in nails, brittleness, fungal infection o Head, face, neck – Headaches, injury, dizziness, loss of consciousness, swelling, lumps, pain • Family history of illnesses in these systems Physical Exam Findings (address findings for each item) Skin • Inspect – color, uniformity, rashes, lesions, etc. • Palpate – temperature, texture, turgor Hair • Inspect – color, distribution, hygiene, etc. • Palpate – texture Nails • Inspect – color, cracking, ridges, etc. • Inspect/palpate – clubbing, capillary refill Head/face • Inspect – facial features, symmetry, etc. • Palpate – head, scalp • Palpate – frontal and maxillary sinuses • Palpate – temporomandibular joint (TMJ) • Assess trigeminal nerve (CN-V) – masseter muscle, facial sensation • Assess facial nerve (CN-VII) – facial expressions Neck • Inspect – neck, neck vein distention, trachea, etc. • Palpate – trachea, tracheal tug • Palpate – thyroid • Palpate – lymph nodes • Assess spinal accessory nerve (CN-XI) – neck rotation, shoulder shrug; both with/without resistance Analysis: Abnormalities and/or Health Risks Provide your analysis of actual/potential risks based on the information from the history and physical exam.

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