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?
ORDER HERE
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.