Osce Instructions: Abdomen

Subjective data
1. Reason for seeking care
2. Demographic data
- age, marital status, # of kids, name, occupation
- Pain Assesment/symptom assessment do assessment
for abdomnical pain
- Pallatiave or Provocative what makes it better or worse
- Quality- what kind of pain is it
- R region or radiation, where is it did it move anywhere
- U- do you understand why it happened
- S- severity on a scale of 1-10 how intense is the pain
- T- timing is it worse at certain times or with specific activities
- A- associated symptom fullness in the ear, discharge,
difficulty swallowing, fever, runny nose, cough, headache,
dizziness
3. General Health History Personal
- heart disease, blood disorder, cancer
4. Relevant Health History
- GI history, ulcers, gallbladder disease, pancreatic problems,
appendicitis, bowel disorders, GERD, heart burn, IBs, kidney or
bladder problems, abdominal surgeries
5. Family Relevant History
- GI disease, cancer,p ancreatis, gallbladder diseases, bowel
disorders,ulcvers
6. Allergies
-food, environment, medication
7. Medications
-herbal, prescription, otc ,vitamins
8. Environmental Exposure
- chemicals, toxins, infections, allergens, occupational or
recreational exposure
9. Self care questions
- smoker, chewing tobacco, takes illicit drugs ( with explanation),
immunizations up to date, exercise
10.
Specific health care behaviors
- change in appetite, weight, or any difficult swallowing
- food intolerances
- bowel habits/functions: last BM, consistency, amount of flatus,
use of laxatives
11.
Abuse Assessment
- physical, financial, emotionally ,sexually
12.
General survey
- behavior LOC x4

- mobility- even gait 10-15 cm

- physical appearance > even skin colour throughout, apparent
signs of distress
- body structure- symmetrical or unsymmetrical
13.
Vital signs
- pulse 60bpm, start at zero, 0-4+, rhythm, amplitude, elasticity,
normal
- blood pressure, 2 step, Systolic over Diastolic 10-139/60-89
- Respirations 12-24 if over 65, 10-20 under 65) , breathing is
eupnic, relaxed, even, automatic
14.