Rachel Adler Alcohol Use Disorder shadow health transcript
Transcript
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Hello. My name is xxx, I will interview you and conduct a physical exam
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Greet |
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Hi. Thanks for being here.
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What brings you here? Rachel Adler Alcohol Use Disorder shadow health transcript
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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.
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Did you get an injury?
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Other than my wrist? No, I don’t think so.
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Were you attempting suicide? (Clarified to Have you ever attempted suicide?.)
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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.)
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Did you lose consciousness?
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I passed out in the car crash. I don’t remember how it happened.
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Were you wearing a seatbelt?
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I always wear my seatbelt. Even when I’m drunk driving, apparently.
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Did you drink before the accident?
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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.
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Did you drive carefully?
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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.
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When did the pain start?
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The pain probably started around the moment when I passed out and my car hit that pole.
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Where is your pain located?
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My wrist hurts the most. The right one, in the brace.
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What makes your pain worse?
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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.
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Am sorry about that
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Empathize |
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Ha, thanks.
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What relieves your pain?
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The ibuprofen has helped the pain. That, and the sling.
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Does rest improve your pain?
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Yeah, resting here does help.
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What is your pain like?
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It’s kind of this constant ache Rachel Adler Alcohol Use Disorder shadow health transcript.
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Any sharp pain?
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No, I wouldn’t describe it that way. It’s more of an ache.
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How would you rate your pain level? Rachel Adler Alcohol Use Disorder shadow health transcript
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I’d say my pain is about a two out of ten.
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Does your medication improve the pain?
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The ibuprofen has helped the pain. That, and the sling.
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Do you have any other health problems?
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I don’t have any illnesses.
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Any history of mental disorder?
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I’ve never been diagnosed with a mental illness.
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Any history of depression?
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No, no one’s ever told me I have depression.
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Any stress?
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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.
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Am sorry about that
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Empathize |
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Thanks. Wish I were kind to myself like that.
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Any suicidal thoughts?
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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.
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Have you ever attempted suicide?
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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.
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do you feel confused about your life?
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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.
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Am sorry about that
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Empathize |
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Thanks for getting it.
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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?.)
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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.)
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What makes you think about dying? (Clarified to Why do you think life is not worth living?.)
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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.)
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Am sorry about that
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Empathize |
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Thanks. Wish I were kind to myself like that.
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Assess vitals
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Inspected right eye
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Inspected left eye
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Inspected right eye
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Inspected left eye
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Inspected left arm
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Inspected right arm: right hand is normal, right wrist has redness and swelling
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Inspected left arm: no visible abnormalities Rachel Adler Alcohol Use Disorder shadow health transcript
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Inspected left wrist: no visible abnormalities
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Inspected left hand: no visible abnormalities
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Inspected right arm: no visible abnormalities
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Inspected right wrist: no visible abnormalities
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Inspected right hand: no visible abnormalities
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Inspected left arm: no visible abnormalities
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Auscultated breath sounds
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Auscultate heart sounds
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Palpated radial arteries
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Tested capillary refill
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Assessed general appearance: indirect eye contact, tension and rigidity, clean clothing, and appropriate level of grooming Rachel Adler Alcohol Use Disorder shadow health transcript
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Assessed attitude: suspicious, guarded, or evasive
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Assessed speech: expected rate of speech, loud speech volume, and no appreciable issues with articulation
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Assessed mood and affect: stable mood and a balanced affect
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Assessed thought process: no presence of thought disturbances
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Assessed thought content: suicidal ideation but no perceptual disturbances
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Confirmed orientation
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What is your name and date of birth?
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Rachel Adler and I was born. . . [Ms. Adler reports her correct date of birth.]
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What building are you in now?
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We’re in Shadow General Hospital.
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What is the date and year?
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Yeah, it’s . . . [Ms. Adler reports the correct date and year.]
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Assessed cognition
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Count backwards from 100 by 7 until you get to the 60s
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Uh, sure . . . 100, 93, 86, 79… (Ms. Adler finishes the sequence)
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Assessed cognition
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How are apples and oranges alike?
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Those are both types of fruit.
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How are a lake and an ocean alike?
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Obviously those are both bodies of water.
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How are a trumpet and a flute alike?
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Those are both instruments. Wind instruments.
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Assessed cognition
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Repeat and remember burger, tulip, nose, and tea.
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Burger, tulip, nose, tea. Got it.
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How did you celebrate your last birthday?
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It was pretty low key actually. I went to dinner with some friends, then we watched movies at my place. It was nice.
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Repeat the four words from before
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Burger, tulip, nose, and tea.
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Copy the shapes exactly as you see them
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I’ll have to do it with my other hand because of my wrist, but luckily I’m pretty good with both.
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Assessed insight: demonstrates limited or no awareness of illness and/or is unwilling to seek treatment
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Assessed judgment: demonstrates good judgment
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What would you do if you found a stamped envelope on the sidewalk?
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Uh, I guess I’d try to drop it in a post box somewhere.
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