Narrative Documentation:

Subjective Data:

An 18-year old Filipino woman with history of skin lesion. Reported long term and inactive acne and
pruritus or itchiness of feet triggered every time the patient ate seafood. Uses pimple removers,
rejuvenating set, and ointments to get rid of pimples but it just temporarily go away. Use cebu de macho
and take anti-histamine when experiencing itchiness. Started experiencing it during 2 nd year high school
until now she is in Grade 12, 5 years in total. In their family, patient’s father sometimes experience skin
problem specifically itchiness and forms plaque in the feet. Uses deodorant therefore no uncontrolled
body odor. Have one pair of ear piercing. Denies having tattoo and birthmarks. Not experiencing hair
loss. Patient said she did not observed any color changes in her nails and she does not bite her nail.

Didn’t undergone any treatment like laser treatment to get rid of her lesions because of lack of financial
need. Aside from seafood, poultry foods also trigger her pimples and itchiness. Does not experiencing
any chronic illness. The patient was vaccinated therefore she rarely get sick. Have normal menstrual flow
usually lasts for 4 days. Not diagnosed with depression or anxiety but experiencing stress because of
school works. Sometimes-patient sleep late at night.

Aside from her father, her mother, brother, older sister and twin experiencing secondary lesion –
keloids. Her father, eldest brother, and she, do not have any keloids. She does not have idea about the
skin problems of her extended family because of distance.

The patient is usually exposed to sunlight because they live in a farm and usually do gardening. Starts at
9AM to 4PM but they don’t work continuously. Denies the use of chemicals while gardening. Sometimes
experience redness and irritation in pimples especially when overly exposed to sunlight. Her current skin
care is typical routine, which are facial wash, toner and cream. The specific brand is Fresh Formula,
which has mild formulation that does not irritate her pimples. She eats a balanced diet like vegetables,
fish, and meat. Drinks a lot of water, which helps the patient, lessen her pimples.

Objective Data:

The patient’s skin color is uniformly medium brown but lighter on non-sun-exposed areas. No foul-
smelling odor was noted. Skin is smooth, warm and dry. Turgor with immediate recoil at the clavicle. No
edema noted. Patient has normal cephalic, proportion to her body. No depressions or deformities. No
involuntary twitching observed. Eyelids are normal and symmetrical. Sclera is white and shiny.
Conjunctivae is pink and no presence of drainage. Nose is in the midline, no presence of lesions. Nasal
mucosa is pinkish and no abnormalities seen. Cheeks are symmetrical, there is presence of papule with
hyperpigmentation; clustered configuration. Lips is symmetrical; soft and smooth; no abnormalities
seen; pinkish in color; and no bleeding, or edema seen. Oral cavity is normal; no swelling and no
exudate; pinkish; and no pallor, jaundice and cyanosis indication. Chin down to the patient’s neck is
perfectly normal, no lesions or bulging masses is present. Hair is dark brown, shoulder-length, no
infestation and shiny. Hair and scalp without oiliness or dandruff observed. Hair is fairly distributed all
over the body. Terminal and vellus hair is normal. There is presence of lesions on the dorsum of the feet
of the patient specifically elevated plaque on the left foot measures 1.2 cm and in the right foot
measures 1 cm that extended around her toenails particularly both of the hallux; and middle and fifth
toe in the left foot. The configuration is clustered and the color is brown. No serous fluid or pus present.
No emanating odor occurred in the lesion. Secondary lesion – stretch marks found in the back of both
knees. It has linear configuration and the color is glistening white. No bed sore found on pressure points.
Nail beds are pink. Fingernails are clean and well-trimmed. No formation of finger clubbing. Toenails are
hard, smooth, immobile, trimmed and clean. Cuticles are smooth; no detachment of nail plate. Capillary
refill in fingernails is immediate.