**Medical Record Write-Up**
Patient Name: John Doe
Age: 35
Gender: Male
Date of Assessment: June 15, 2022
**General Survey:**
The patient appears alert and oriented, with normal speech and behavior. No signs of distress or abnormal movements noted.
**Neurological Assessment:**
**Subjective Data:**
The patient reports no history of headaches, dizziness, seizures, or changes in memory. Denies any numbness, tingling, weakness, or motor difficulties.
**Objective Data:**
Cranial nerve exam within normal limits. Muscle strength and tone intact. Reflexes symmetric and brisk. Sensation intact bilaterally.
**Respiratory Assessment:**
**Subjective Data:**
The patient reports occasional shortness of breath with exertion but denies any cough, sputum production, chest pain, or wheezing. No history of respiratory conditions.
**Objective Data:**
- Respiratory rate: 16 breaths per minute
- Lung expansion symmetric bilaterally
- No cyanosis or clubbing noted
- Respiratory effort appears effortless
**Data Collected Through Observation:**
- Skin color is pink and warm
- No use of accessory muscles
- No labored breathing observed
**Data Collected Through Palpation:**
- No tenderness or masses palpated over the chest wall
**Data Collected Through Percussion:**
- Resonance heard over lung fields
**Data Collected Through Auscultation:**
- Breath sounds clear and equal bilaterally
- No adventitious sounds heard
**Impression:**
Overall, the patient presents with a normal neurological and respiratory assessment. No significant abnormalities noted during the examination. Follow-up may be necessary if symptoms persist or worsen.
you will summarize a hypothetical respiratory assessment (you will not actually perform one, you will just summarize your "results" as if you were to perform one) on a word processing document. You will summarize your findings as a medical record write up:
Your write-up will include a description of: a respiratory palpation, percussion, and auscultation through their clothing, preferably a light t-shirt. You will include both simple key identifying information and more subjective or abstract information like how your patient is feeling. This, will include your extended discussion interview with your patient as well as the following information:
a general survey (neurological and respiratory)
neurological:
subjective data
objective data
data collected through palpation
respiratory:
subjective data
objective data
data collected through observation
data collected through palpation
data collected through percussion
Data collected through ausculation
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