Medical Record Write-Up:
Patient Name: Jane Doe
Age: 45
Date of Assessment: June 15, 2021
General Survey:
Neurological: The patient appears alert and oriented, with no signs of confusion or disorientation. She is able to answer questions promptly and coherently.
Respiratory: The patient is sitting upright comfortably in a chair, breathing at a normal rate with no signs of distress.
Neurological Assessment:
Subjective Data: The patient reports no recent headaches, dizziness, or changes in sensation or strength in her limbs.
Objective Data: Cranial nerves intact, patient able to follow commands and move all extremities purposefully.
Palpation: No abnormalities noted in muscle strength or tone during examination.
Respiratory Assessment:
Subjective Data: The patient reports no recent cough, phlegm production, or shortness of breath.
Objective Data:
- Observation: Normal chest expansion and respiratory rate.
- Palpation: No tenderness or abnormalities noted upon palpation of the chest wall.
- Percussion: Resonant percussion notes heard throughout lung fields.
- Auscultation: Clear breath sounds heard bilaterally, no adventitious sounds present. Respirations regular without wheezing or crackles.
Overall, the patient presents with a normal neurological and respiratory assessment. She denies any respiratory symptoms and appears to have normal lung function upon examination. The patient is feeling well and expresses satisfaction with her current health status. Further monitoring of respiratory symptoms may be warranted in the future.
you will summarize a hypothetical respiratory assessment, 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 auscultation
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