HEAD, EYES, EARS, NOSE , THROAT

HEADHead is normocephalic, symmetrical to the body, no gross deformities, lumps, hematomas

or tenderness noted. The hair is short, white in color, thin, dry in texture with receding hairline. The scalp is slightly movable along with the cranium, no lesions, scars or parasite but with dandruff/flakes noted. Temporal arteries are palpable but not visible.

FACEFace is brown in color, symmetrical, smooth with wrinkles, no lesions, scars, abnormal

fascies/facial expression, jerking or involuntary movements noted.

EYESEyebrows are symmetrical, white, thin and well distributed. Eyelashes are black, short, and

present on both upper and lower eyelids. Eyelid has no lesion, scars, tenderness or edema. Negative for lid lag, no exophthalmos or enopthalmos noted. Palpebral fissure is about 4cm in diameter. Periorbital area are not sunken, no swelling or hematoma, no tenderness of eyeball upon palpation. Palpebral and bulbar conjunctivas are pinkish, no swelling or hematoma noted. The sclera is white, no lesion or scars noted. The cornea is opaque, no ulcer or foreign bodies noted. Iris is round and black in color. Pupils are asymmetrical about 3mm on the left eye and 3.5mm on the right eye, round and reactive to light and accommodation. Positive direct and consensual light reflex. Intact extraocular muscles and visual fields on the left eye, right eye can only see lights.

EARSEars are brown, triangular and symmetrical. Small lesion noted on the left earlobe at about

1cm in diameter. No tenderness over the pinna and mastoid area. External auditory canal is patent; walls are pinkish, no discharges or foreign bodies noted. Tympanic membrane is pearly white, no bulging or perforation noted. Patient can hear on both ears by rubbing of fingers. No palpable lymph nodes.

NOSENose is symmetrical and in the midline. No flaring of ala nasi, no secretions, no epistaxis

noted, vestibules are patent, with finely distributed cilia, mucosa is pinkish. Nasal septum is in the midline and no perforation noted. No tenderness on frontal and maxillary sinuses. No clouding of sinuses upon transillumination.

MOUTH AND THROAT

Lips are pale in color and dry. Lateral part of the upper lip is swollen with sore at about 1.5cm in diameter. Buccal mucosa is pinkish, with multiple sores noted. Tongue is pinkish with multiple white patches, located medially, no lateral deviation upon protrusion and retraction. Only left upper premolar tooth present. Gingiva is pinkish, no recession, no bleeding noted.

NECKSkin is brown. No tenderness, no mass and no lesion noted. Neck is symmetrical, no deviation, with visible neck veins. Trachea and hyoid are in the midline. Lymph nodes are non-palpable. Thyroid is palpable and visible but not tender.