Peer Assessment Documentation

Chief complaint

• Pt has no complaints

• is here for peer assessment.

HPI

• Pt has good health status

• Pt has no pertinent PMHx

General Survey

ROS

• Fever?

• SOB?

• Any significant weight loss?

Mental Status

• Responds appropriately to questions

.

• A&O x4

.

• Demonstrates reasoning abilities appropriately

.

• Able to follow directions

.

• Memory intact

  • immediate

  • recent

  • past

.

ROS

• How has your day been?

• (A&O x4)

Head/Face

• Hair clean, evenly distributed

.

• Scalp intact

  • no:

    • discoloration

    • mass

    • ttp

.

• CNS VII (facial) nerve intact

.

• CN V (trigeminal) nerve intact to light touch

.

• Palpated jaw muscles

  • = and strong strength

.

• TMJ joint with adequate movement

  • no:

    • ttp

    • clicking

    • popping 

.

• Palpated maxillary and frontal sinuses

  • no ttp

.

ROS

• denies

  • HA

• Reports

  • frequent hair washing

Eyes

• Lids are symmetrical, conjunctiva pink and moist, intact

.

• Lacrimal glands

  • no:

    • masses

    • ttp

    • drainage

    • discoloration

.

• CN II (optic) intact in both eyes

  • Snellen chart: no visual aids

    • OU: 20/20

    • OD: 20/20

    • OS: 20/20

.

• CN III, IV, VI, BL movements intact

  • no pain

.

• PERRLA directly & indirectly

.

ROS

• Denies:

  • blurry vision

  • double vision

  • spots in vision

Ears

• External ears symmetrical and =

  • no discoloration, swelling

  • palpated with no mass or ttp

.

• Inspected ear canals BL

  • no:

    • foreign objects

    • cerumen buildup

    • swelling

    • discoloration

    • mass

    • ttp

    • drainage

    • bleeding

.

• Otoscopic exam done in both ears

  • BL TMs intact

  • appears pearly white

  • no:

    • bulging

    • drainage

    • redness

.

• Whisper test done negative for both ears

  • Gross hearing intact

.

ROS

• Denies

  • tinnitus

  • hearing loss

  • vertigo

Nose Mouth and Throat

• observed external nose

  • no:

    • mass

    • discoloration

    • swelling

    • ttp

  • Septum midline

    • no deviation

.

• Nostrils are patent

  • no:

    • mass

    • drainage

    • bleeding

.

• Penlight exam of the internal nose done

  • Nostril patent

    • no:

      • foreign bodies

      • mass

      • swelling

      • drainage

      • bleeding

  • Mucosa intact, pink, moist 

.

• Oral mucosa pink, moist, intact

  • No:

    • mass

    • bleeding

  • Throat airway patent

    • no:

      • mass

      • swelling

      • redness

      • exudates

  • Tonsils not enlarged

    • no redness

  • Uvula midline

    • no redness or swelling

  • Tongue within normal

    • no swelling or redness

.

• Good Dentition

  • no cavities, abscess

  • Gums pink

    • redness

    • swelling

    • discoloration

.

• CN IX, X intact. Good equal strong movement of tongue and uvula

  • Gag reflex intact

.

ROS:

• Denies

  • rhinorrhea

  • dental sensitivity

  • painful swallowing

Neck

• Palpated lymph nodes with

  • no:

    • swelling

    • ttp

    • discoloration

.

• Trachea midline

  • Palpated

    • no:

      • ttp

      • mass

.

• Head and neck movements strong and =

  • Full ROM

  • no pain

.

• Thyroid not enlarged

  • Palpated

    • no:

      • mass

      • ttp

.

• CN XI (sternomastoid and trapezium) intact

  • Strong and = shoulder shrug

.

ROS

• denies

  • stiffness

  • lumps

  • swelling

Thorax

• AP < LA 1:2

  • no barrel chest

.

• Observed symmetrical appearance of chest

.

• Palpated symmetrical expansion

  • =, symmetrical

.

• Nail beds pink and intact

  • Cap refill < 3 sec

  • no:

    • discoloration

    • clubbing

.

• Auscultate breath sounds in all fields

  • clear and present

.

ROS

• Denies

  • smoking

  • dyspnea

  • asthma

Heart

• All cardinal areas auscultated present

  • S1 & S2 present, regular

  • no murmurs

.

• Apical pulse: 60, radial pulse: 60

  • AP=RP

.

• Palpated apical impulse at PMI at left MCL, 5th ICS

.

• No JVD

.

• BL carotid pulses strong equal +2, auscultated

  • no bruits

.

ROS

• Denies

  • palpitations

  • arrhythmias

  • tachycardia

Peripheral Vascular System

• Carotid pulses = BL, strong +2

.

• Radial pulses = BL, strong +2

.

• Brachial pulses = BL strong +2

.

• Dorsalis pedis = BL, equal strong +2

.

• Posterior tibial pulses = BL, strong +2

.

ROS

• Denies

  • Hx

    • blood clots

    • blockages

  • unhealing wounds

Abdomen

• Abdomen inspected symmetrical

  • no:

    • marking

    • pulsations

.

• Auscultated bowel sounds

  • present and normoactive all four quadrants

.

• Palpated suprapubic area/bladder

  • no:

    • distension

    • ttp

.

• Palpated abdomen

  • no:

    • ttp

    • masses

    • rigidity

    • distention

.

• BL CVA palpation

  • no ttp

.

ROS

• Denies

  • surgeries

  • bowel blockages

  • urinary retention

Breast, Genitalia, Rectum

• Male pt instructed on testicular exam using model demonstration.

  • Discussed teaching for screening and instructions for abnormal findings

  • perform monthly at least

.

• Female pt instructed on self-breast exam using model

  • Discussed teaching for screening and instructions for abnormal findings.

  • Perform monthly at least

Musculoskeletal

• spine has adequate curvatures

  • no scoliosis

.

• Palpated spine

  • no:

    • ttp

    • mass

.

• Steady gate

  • no assistance

.

• Full ROM upper/lower BL joints

  • no pain

.

• Muscle strength BL upper/lower limbs strong, =

.

• BL upper extremities 5/5

.

• BL lower extremities 5/5

.

• All movements symmetrical

  • no weakness

.

• Hands grasps strong, = BL

.

• Foot pushes strong, = BL

.

ROS

• Denies

  • ambulatory assistance

  • joint pain

  • limited ROM

Neurological

• Cerebellar function intact

.

• demonstrates good coordination

  • finger-nose movements

  • rapid alternating movements

.

• Balance intact

  • negative Romberg

.

• Sensory perception intact

.

• Superficial touch and superficial pain intact BL upper and lower limbs

.

• Pt reports equal sensation to BL upper elbows and lower knees

.

• Vibratory response in 4 joints intact, =, strong

.

• Deep tendon reflexes intact

.

• Triceps, patellar, plantar deep tendon reflexes present, = BL, all normal, +2

.

ROS

• Denies

  • numbness

  • tingling

  • lack of sensation

Skin

• Overall skin intact

  • no:

    • discoloration

    • mass

    • ttp

    • wounds

    • rashes

    • lesions

.

• Skin turgor < 3 sec

.

• Skin overall with expected coloration

.

• adequate moisture

  • no:

    • cyanotic

    • warm

    • diaphoretic

.

ROS

• Denies

  • recent rash

  • abnormal moles

• Reports

  • adequate hydration