Nursing Health Assessment Documentation Record 212

Name: Gillian Church

System Being Assessed: Gastrointestinal System
CC (chief complaint): abdominal pain
Onset: Began 3 days ago
Location: upper right quadrant abdominal pain
Duration: constant pain since 3 days ago
Characteristics: sharp, stabbing pain
Alleviating/aggravating factors: worsens after eating
Related to factors: feeling very tired
Treatments: modified (BRAT) diet, but no relief
Severity: 9/10 pain scale
HPI (History of Present Illness): How have you been feeling lately?: No
complaints
Medications (Prescribed, OTC, herbals): acetaminophen 500mg PO PRN for
headaches
Allergies: NKA
PMH: Mild depression, anxiety, osteoporosis
PSH: none
FH: brother has depression, mother died at 64 of Parkinsons disease, Father
has hypercholesterolemia, paternal grandfather had hypertension, several
heart surgeries, and past at 91 of CHF, paternal grandmother had dementia,
died at 87, maternal grandmother died at 78 with Alzheimers, paternal
grandfather died at 71 of lung cancer
Social History: Quit smoking cigarettes 9 years ago, drinks 1 (4 oz.) glass of
wine daily, denies recreational drug use
General Survey: T 99.8, P 90 and reg, RR 20 and unlabored, O2 95%, BP
130/90, appears a bit lethargic, and fatigued, hair well distributed, skin is

warm, dry, has yellow tint, pulses 2+, LS CL throughout A&P, non-tenting
skin turgor, Pupils 3m PERRL, 2+ DTRs, cap refill <3, inspected the
abdomen, slightly distended, hypoactive BS, tenderness on palpation in RUQ.