NAME: PINEDA, Nur Ainna E.

Height : 130 cms weight: 24 kgs.

Chief Complaint: Dog Bite on face ; referred to their clinic teacher
BODY PART Technique NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
used

Skin Inspection Uniform in color; no Uniform in color Normal

abrasions or any lesions No abrasions, cuts, bruises
or lesions noted
Well moistened skin. Dry skin Skin is dry due to not daily
application of lotion or any
moisturizer to the skin.
HEAD Round or normocephalic;
smooth, absence of Round smooth, no nodules Abnormal.
SKULL & Inspection nodules or masses; or any masses, with Dog bites on face may
FACE Palpation symmetric facial symmetrical facial cause any entry of rabies
movements. movements virus in the body which in
(+) dog bite wounds on the future can harm the
face near the eyes patient.
HAIR Inspection Even distribution of hair, Even distributed hair, Abnormal.
resilient thick hair with resilient thick hair Resiliency and distribution
no signs of infections or But with signs of is normal. However, hair is
infestations. infestations of (+) infested with pediculosis
pediculosis because of inappropriate
hygiene acts e.g., bathing.
Eyebrow Inspection
Evenly distributed hair; Evenly distributed hair; Normal
eyebrows symmetrically eyebrows symmetrically
aligned; aligned;

Eyes Inspection Lids close symmetrically; Lids close symmetrically, Normal

shiny smooth, pinkish shiny smooth, pinkish
conjunctiva; no edema or conjunctiva; no noted
tenderness. edema or tenderness.

Eyelashes Inspection Equally distributed, Equally distributed Normal

Curled slightly outward Curled slightly outward

Eyelids Inspection Skin intact, Intact Skin, no discharge Normal

No discharge, noted

Pupils (color , Inspection No No discoloration, Lids Normal

shape and discoloration, close symmetrically
symmetry of Lids close symmetrically
size)
Black in color, equal in Black in color, equal in Normal
size normally 3-7 mm in size normally 3-7 mm in
diameter, diameter, round smooth
round smooth border , iris border, iris flat and round
flat and round.
EAR Inspection color same as facial skin Color same as facial skin Normal

symmetrical; mobile, Symmetrical, mobile, firm Normal

firm and not tender; and not tender

No notable discharges No notable discharges Normal

normal voice tones Normal voice tones audible Normal

audible

NOSE AND Inspection Symmetric and straight; Symmetric and straight Normal
SINUSES
no discharge or flaring; With discharge, but with Normal
not tender, no lesions. no flaring
No tenderness and lesions

Uniform in color Uniform in color Normal

Air moves freely as the Air moves freely in one One nare is blocked
patient breaths through nares, but one nares is because of the common
the nares. blocked with (+) whitish cold experienced due to the
discharge extreme cold condition
here in Manila.
No tenderness in Not tenderness in