N317 Health Assessment documentation – demographics and general assessment.

01/16 /19, 1509, M.K, 27 y/o female, African American, nursing student. VS: BP: 110/74 R arm sitting; T: 99 F. oral; P: 72 radial RRR; R: 18 laborated RRD; O2 98% room air; Ht: 5.25ft, Wt: 132 ibs. BMI: 37.4, NKDA; Pain “6/10”.

Reason for seeking care: “Car accident” three weeks ago “lower back pain” and feelfeels "dizziness and fatigue,” “6/10”. Occurs once every four 4(4) hrs, lastlasts 30 minutes. Bright light, TV, cold weather, and loud noises make it worse. Lying down on bed and talkingtaking Tylenol makemakes it better. Associated with car accident. It has been getting worse. Denies any food allergies, think. Thinks she “has a back injury.”
General Assessment: A&OX4, well-groomed, appropriately dressed for the weather, clean hygiene, with no odors. Pleasant affect; no signs of distress. Body structure is symmetrical and proportional to height, sitting upright. SN, WSU.