Rachel Adler Alcohol Use Disorder shadow health transcript

Rachel Adler Alcohol Use Disorder shadow health transcript
Rachel Adler Alcohol Use Disorder shadow health transcript
Transcript

Started: Jun 11, 2022 | Total Time: 172 min

All Lines (164)Interview Questions (119)Statements (14)Exam Actions (31)

Hello. My name is xxx, I will interview you and conduct a physical exam

Greet

06/16/22 10:13 PM EDT

Hi. Thanks for being here.

What brings you here? Rachel Adler Alcohol Use Disorder shadow health transcript

Question

06/16/22 10:17 PM EDT

I don’t know what happened. They told me I was in a car accident, that I hit a pole and I’m getting a DUI. That’s how I hurt my wrist. I don’t care what happened, I kind of wish it had been worse.

Did you get an injury?

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Question

06/16/22 10:18 PM EDT

Other than my wrist? No, I don’t think so.

Were you attempting suicide? (Clarified to Have you ever attempted suicide?.)

Question

06/16/22 10:22 PM EDT

No, I’ve never attempted suicide. I’ve never planned anything. Before last night, I wasn’t trying to hurt myself. I just wish things were easier, and if I’d died last night, I’d be free of being so sick and tired of everything Rachel Adler Alcohol Use Disorder shadow health transcript. (Clarified to if I have ever attempted suicide.)

Did you lose consciousness?

Question

06/16/22 10:30 PM EDT

I passed out in the car crash. I don’t remember how it happened.

Were you wearing a seatbelt?

Question

06/16/22 10:34 PM EDT

I always wear my seatbelt. Even when I’m drunk driving, apparently.

Did you drink before the accident?

Question

06/16/22 10:34 PM EDT

Yeah. I was. I think I had at least five drinks. I was at a party with my friends, so, I didn’t think it was a big deal. Shows you where that gets you, I guess.

Did you drive carefully?

Question

06/16/22 10:35 PM EDT

Honestly, I didn’t care that I was driving drunk. I mean, I’ve done it before, all my friends do it, I didn’t think it was a big deal. I was too upset to care, anyway. I didn’t really think I was going to get hurt, but, like, at the same time, I didn’t care what happened to me.

When did the pain start?

Question

06/16/22 10:36 PM EDT

The pain probably started around the moment when I passed out and my car hit that pole.

Where is your pain located?

Question

06/16/22 10:37 PM EDT

My wrist hurts the most. The right one, in the brace.

What makes your pain worse?

Question

06/16/22 10:37 PM EDT

It hurts pretty bad when I move it. If I bend or twist it, or if I try to pick something up, it hurts a lot.

Am sorry about that

Empathize

06/16/22 10:38 PM EDT

Ha, thanks.

What relieves your pain?

Question

06/16/22 10:38 PM EDT

The ibuprofen has helped the pain. That, and the sling.

Does rest improve your pain?

Question

06/16/22 10:39 PM EDT

Yeah, resting here does help.

What is your pain like?

Question

06/16/22 10:40 PM EDT

It’s kind of this constant ache Rachel Adler Alcohol Use Disorder shadow health transcript.

Any sharp pain?

Question

06/16/22 10:40 PM EDT

No, I wouldn’t describe it that way. It’s more of an ache.

How would you rate your pain level? Rachel Adler Alcohol Use Disorder shadow health transcript

Question

06/16/22 10:40 PM EDT

I’d say my pain is about a two out of ten.

Does your medication improve the pain?

Question

06/16/22 10:41 PM EDT

The ibuprofen has helped the pain. That, and the sling.

Do you have any other health problems?

Question

06/16/22 10:42 PM EDT

I don’t have any illnesses.

Any history of mental disorder?

Question

06/16/22 10:42 PM EDT

I’ve never been diagnosed with a mental illness.

Any history of depression?

Question

06/16/22 11:14 PM EDT

No, no one’s ever told me I have depression.

Any stress?

Question

06/16/22 11:15 PM EDT

The last year has been hard, but I’ve been especially stressed out for the last six months. It’s been so tough to keep my grades up at school, to deal with my parents, and then to have problems with my friends . . . I wish I could be a normal carefree college student, but that’s never going to happen now.

Am sorry about that

Empathize

06/16/22 11:16 PM EDT

Thanks. Wish I were kind to myself like that.

Any suicidal thoughts?

Question

06/16/22 11:17 PM EDT

I don’t have a plan, if that’s what you mean. Before last night, I didn’t want to kill myself. Right now . . . I don’t know. Everything is so hard, and I wish it would all just stop.

Have you ever attempted suicide?

Question

06/16/22 11:17 PM EDT

No, I’ve never attempted suicide. I’ve never planned anything. Before last night, I wasn’t trying to hurt myself. I just wish things were easier, and if I’d died last night, I’d be free of being so sick and tired of everything.

do you feel confused about your life?

Question

06/16/22 11:18 PM EDT

I don’t know. I haven’t thought about physically killing myself or how I would do it or anything. It’s more just wishing not to be here. Rachel Adler Alcohol Use Disorder shadow health transcript It would be so much easier.

Am sorry about that

Empathize

06/16/22 11:40 PM EDT

Thanks for getting it.

Why do you wish you had died? (Clarified to Why do you think it would be better if you had died in the car accident?.)

Question

06/16/22 11:43 PM EDT

Well, it would be so much better if I didn’t have to put up with the stress of life anymore. Like, I didn’t care if I could’ve hurt myself last night, even though I know drinking and driving is bad . . . in some ways, it might have been better if I had just died last night. Then I wouldn’t have to go through all this. I wouldn’t have to face the court for this DUI, wouldn’t have to face my parents . . . (Clarified to why I think it would be better if I had died in the car accident.)

What makes you think about dying? (Clarified to Why do you think life is not worth living?.)

Question

06/16/22 11:45 PM EDT

Well, it would be so much better if I didn’t have to put up with the stress of life anymore. Like, I didn’t care if I could’ve hurt myself last night, even though I know drinking and driving is bad . . . in some ways, it might have been better if I had just died last night. Then I wouldn’t have to go through all this. I wouldn’t have to face the court for this DUI, wouldn’t have to face my parents . . . (Clarified to why I think life is not worth living.)

Am sorry about that

Empathize

06/17/22 12:40 AM EDT

Thanks. Wish I were kind to myself like that.

 Assess vitals

Exam Action

06/17/22 12:40 AM EDT

 Inspected right eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected left eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected right eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected left eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected left arm

Exam Action

06/17/22 12:40 AM EDT

 Inspected right arm: right hand is normal, right wrist has redness and swelling

Exam Action

06/17/22 12:40 AM EDT

 Inspected left arm: no visible abnormalities Rachel Adler Alcohol Use Disorder shadow health transcript

Exam Action

06/17/22 12:41 AM EDT

 Inspected left wrist: no visible abnormalities

Exam Action

06/17/22 12:41 AM EDT

 Inspected left hand: no visible abnormalities

Exam Action

06/17/22 12:41 AM EDT

 Inspected right arm: no visible abnormalities

Exam Action

06/17/22 12:42 AM EDT

 Inspected right wrist: no visible abnormalities

Exam Action

06/17/22 12:42 AM EDT

 Inspected right hand: no visible abnormalities

Exam Action

06/17/22 12:42 AM EDT

 Inspected left arm: no visible abnormalities

Exam Action

06/17/22 12:43 AM EDT

 Auscultated breath sounds

Exam Action

06/17/22 12:44 AM EDT

 Auscultate heart sounds

Exam Action

06/17/22 12:44 AM EDT

 Palpated radial arteries

Exam Action

06/17/22 12:44 AM EDT

 Tested capillary refill

Exam Action

06/17/22 12:44 AM EDT

 Assessed general appearance: indirect eye contact, tension and rigidity, clean clothing, and appropriate level of grooming Rachel Adler Alcohol Use Disorder shadow health transcript

Exam Action

06/17/22 12:45 AM EDT

 Assessed attitude: suspicious, guarded, or evasive

Exam Action

06/17/22 12:45 AM EDT

 Assessed speech: expected rate of speech, loud speech volume, and no appreciable issues with articulation

Exam Action

06/17/22 12:45 AM EDT

 Assessed mood and affect: stable mood and a balanced affect

Exam Action

06/17/22 12:45 AM EDT

 Assessed thought process: no presence of thought disturbances

Exam Action

06/17/22 12:46 AM EDT

 Assessed thought content: suicidal ideation but no perceptual disturbances

Exam Action

06/17/22 12:46 AM EDT

 Confirmed orientation

Exam Action

06/17/22 12:46 AM EDT

What is your name and date of birth?

Question

06/17/22 12:46 AM EDT

Rachel Adler and I was born. . . [Ms. Adler reports her correct date of birth.]

What building are you in now?

Question

06/17/22 12:47 AM EDT

We’re in Shadow General Hospital.

What is the date and year?

Question

06/17/22 12:47 AM EDT

Yeah, it’s . . . [Ms. Adler reports the correct date and year.]

 Assessed cognition

Exam Action

06/17/22 12:48 AM EDT

Count backwards from 100 by 7 until you get to the 60s

Question

06/17/22 12:49 AM EDT

Uh, sure . . . 100, 93, 86, 79… (Ms. Adler finishes the sequence)

 Assessed cognition

Exam Action

06/17/22 12:49 AM EDT

How are apples and oranges alike?

Question

06/17/22 12:49 AM EDT

Those are both types of fruit.

How are a lake and an ocean alike?

Question

06/17/22 12:50 AM EDT

Obviously those are both bodies of water.

How are a trumpet and a flute alike?

Question

06/17/22 12:50 AM EDT

Those are both instruments. Wind instruments.

 Assessed cognition

Exam Action

06/17/22 12:50 AM EDT

Repeat and remember burger, tulip, nose, and tea.

Question

06/17/22 12:51 AM EDT

Burger, tulip, nose, tea. Got it.

How did you celebrate your last birthday?

Question

06/17/22 12:51 AM EDT

It was pretty low key actually. I went to dinner with some friends, then we watched movies at my place. It was nice.

Repeat the four words from before

Question

06/17/22 12:52 AM EDT

Burger, tulip, nose, and tea.

Copy the shapes exactly as you see them

Question

06/17/22 12:52 AM EDT

I’ll have to do it with my other hand because of my wrist, but luckily I’m pretty good with both.

 Assessed insight: demonstrates limited or no awareness of illness and/or is unwilling to seek treatment

Exam Action

06/17/22 12:53 AM EDT

 Assessed judgment: demonstrates good judgment

Exam Action

06/17/22 12:53 AM EDT

What would you do if you found a stamped envelope on the sidewalk?

Question

06/17/22 12:54 AM EDT

Uh, I guess I’d try to drop it in a post box somewhere.


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