Medical Interview Transcript, Exams of Nursing

Download Medical Interview Transcript and more Exams Nursing in PDF only on Docsity! 2 Damien Brooks Transcript exams question with correct answer latest updated 2023 Hello, I am xxx. I will be interviewing you today and later perform a physical examination 02/05/21 10:42 PM PST Hey. Page 1 of 112 2 What is your name? Questi on 02/05/21 10:43 PM PST Damien Brooks and my birthday is July 25th, if you want to get me anything. [AUDIO COMING SOON] Oka y Em pat Page 2 of 112 2 How did you sustain the bump? (No matching questions found.) Question 02/05/21 10:44 PM PST What happe ned? Quest ion 02/05/21 10:44 PM PST I’m not really sure, to be honest. Page 5 of 112 2 I und erst and Emp athi ze 02/05/21 10:44 PM PST Page 6 of 112 2 Cool, I appreciate that. Di you fall? (Clarified to Did you fall?.) Question 02/05/21 10:45 PM PST Yeah, I took a dive. I don’t remember it really at all though, but I can tell I hit my head. No idea how it happened, usually I shred. (Clarified to if I fell.) Page 7 of 112 2 why do you not wear helmet? Question 02/05/21 11:03 PM PST No one does, really. It looks goofy. Especially on film. I dunno . . . I just kind of got out of the habit. It is always safe to wear sports safety gear such as helmet Educate Page 10 of 112 2 02/05/21 11:04 PM PST Ok, I’ll keep it in mind. Do you take alcohol ? Questio n 02/05/21 11:04 PM PST No, officer. Do you Page 11 of 112 2 take illegal drugs? Question 02/05/21 11:04 PM PST Page 12 of 112 2 Do you have difficulties moving your extremities? (Clarified to Are you having any issues moving your legs?.) Question 02/05/21 11:08 PM PST I’m not feeling awesome right now, but I can move around okay. (Clarified to if I have difficulty moving my legs.) Do you Page 15 of 112 2 have any tingling? Question 02/05/21 11:09 PM PST No, no tingling or anything. Do you have ear problem? (Clarified to Do you have ringing in your ears?.) Question 02/05/21 11:09 PM PST No, I don’t have any ringing in my ears. [AUDIO COMING SOON] (Clarified to if I have Page 16 of 112 2 ringing in my ears.) Do you have memory problems? Page 17 of 112 2 Haven’t had any muscle spasms. Page 20 of 112 2 Do you have gait or balance problem? Question 02/05/21 11:11 PM PST I can walk pretty OK, it’s my head that’s bothering me. What is your relationship with the patient? Question Page 21 of 112 2 02/05/21 11:12 PM PST I’m his stepfather. What happened to your step- son? (Clarified to Talk to me about what had happened to your son?.) Question 02/05/21 11:14 PM PST He was at the skatepark after school, like he usually is, and he fell off his board while doing a grind. He didn’t have a helmet on, Page 22 of 112 2 ? Question 02/05/21 11:17 PM PST Yes, Damien’s had a headache since he got home. Does he have dizziness? (No matching questions found.) Question 02/05/21 11:17 PM PST Did he have Page 25 of 112 2 dizzines s? Questio n 02/05/21 11:17 PM PST Page 26 of 112 2 I didn’t give him anything at home, but they gave him some medication when we got here — acetaminophen, I think. Did he have confusion? (No matching questions found.) Question 02/05/21 11:18 PM PST Did your son have scalp hematoma? (No matching questions found.) Question Page 27 of 112 2 Is your son son complaining of light sensitivity? (No matching questions found.) Question 02/05/21 11:20 PM PST Is your son complaining of light sensitivity? (Clarified to Has your son been sensitive to light?.) Question 02/05/21 11:20 PM PST Yes, definitely. (Clarified to if Page 30 of 112 2 my son has been sensitive to light.) Did he report vomiting? (No matching questions found.) Question 02/05/21 11:21 PM PST Did he have any vomiting? (Clarified to Has your son vomited?.) Question 02/05/21 11:21 PM PST Page 31 of 112 2 It was after Damien came home and told me he had fallen. He was feeling dizzy and had a headache. He threw up pretty soon after that, and that’s when I decided to drive him over here. (Clarified to if my son has vomited.) Page 32 of 112 2 02/05/21 11:27 PM PST How frequent is the headache? (No matching questions found.) Page 35 of 112 2 Question 02/05/21 11:28 PM PST Describe the frequency of the pain (No matching questions found.) Question 02/05/21 11:28 PM PST did you notice confusion? (Clarified to When did you notice your son’s symptoms?.)Question02/05/21 11:29 PM PST Page 36 of 112 2 He’s been dizzy and confused at least since he got home. Kyle said he was complaining about both on the walk back from the skatepark. (Clarified to when I noticed my sons symptoms.) Did you notice dizziness? (Clarified to Did you see blood?.) Question 02/05/21 11:29 PM PST I didn’t notice any bleeding. [AUDIO COMING SOON] (Clarified to if I saw blood.) Page 37 of 112 2 Questio n 02/05/21 11:30 PM PST He was balancing on a rail and just lost his balance. His friend Kyle was recording it, so I watched the video. A hard thing to see. did he lose conscious ness? Question 02/05/21 11:34 PM PST Page 40 of 112 2 Yeah, the fall knocked Damien unconscious. Page 41 of 112 2 What are relieving factors for the pain? Question 02/05/21 11:52 PM PST I gave him an ice pack and laid him down on the couch. I tried dimming the lights too. But once he threw up, I decided I was out of my depth and drove him here. What makes the pain Page 42 of 112 2 Has he had all vaccinations? (Clarified to Does your son have all his vaccines?.) Question 02/05/21 11:54 PM PST Yes, he’s got all his shots. (Clarified to if my son is vaccinated.) That is great. Vaccinations are very important for good health Educate 02/05/21 11:54 PM PST Page 45 of 112 2 I gotcha, loud and clear. Has he ever been hospitalize d? Question 02/05/21 11:55 PM PST Damien’s never been to the hospital before. We’re very lucky, especially if he hasn’t been wearing his helmet like this time. He’s definitely fallen in the past. Page 46 of 112 2 Has he ever had head injury? (Clarified to What previous head injuries has your son had?.) Page 47 of 112 2 Question 02/05/21 11:57 PM PST Page 50 of 112 2 Really just acetaminophen when he has a fever and the like. He almost never takes any medication at all. Is your son having dizziness? (No matching questions found.) Question 02/05/21 11:58 PM PST Any eye problem for your son? (No matching questions found.) Question Page 51 of 112 2 02/05/21 11:58 PM PST Any eye problem? (No matching questions found.) Question 02/05/21 11:59 PM PST Does your son have eye problem? (No matching questions found.) Question 02/05/21 11:59 PM PST Page 52 of 112 2 (No matching questions found.) Question 02/06/21 12:00 AM PST Does Damien have ear issues? (No matching questions found.) Question 02/06/21 12:00 AM PST Any issues with the ears (No matching questions found.) Question Page 55 of 112 2 02/06/21 12:00 AM PST Page 56 of 112 2 Has your son’s speech changed? (No matching questions found.) Question 02/06/21 12:01 AM PST Is he able to follow instruction s? Question 02/06/21 12:01 AM PST He’s been walking fine. [AUDIO COMING SOON] Page 57 of 112 2 Does your son have issue with movement? (Clarified to Does your son have any balance or gait issues?.) Question 02/06/21 12:03 AM PST Nope, he’s been getting around just fine. (Clarified to if my son has any balance or gait issues.) Exam Action02/06/21 12:12 AM PST Page 60 of 112 2 Inspected head front: No abnormal findings Exam Action 02/06/21 12:12 AM PST Inspec ted left eye Exam Action 02/06/21 12:12 AM PST Page 61 of 112 2 Inspec ted right eye Exam Action 02/06/21 12:12 AM PST Page 62 of 112 2 Action 02/06/21 12:14 AM PST Inspect ed left shoulde r Exam Action 02/06/21 12:14 AM PST Page 65 of 112 2 Inspect ed upper back Exam Action 02/06/21 12:14 AM PST Inspecte d right shoulder Exam Action 02/06/21 12:14 AM PST Page 66 of 112 2 Inspected shoulders from the front Exam Action 02/06/21 12:14 AM PST Inspecte d right shoulder Exam Action 02/06/21 12:14 AM PST Inspect ed Page 67 of 112 2 Inspe ct elbo ws Exam Actio n 02/06/21 12:15 AM PST Inspec ted left wrist Exam Page 70 of 112 2 Action 02/06/21 12:16 AM PST Inspect ed right wrist Exam Action 02/06/21 12:16 AM PST Page 71 of 112 2 Inspect ed both hands Exam Action 02/06/21 12:17 AM PST Insp ect hips Exa m Acti on 02/06/21 12:17 AM PST Page 72 of 112 2 Exam Action 02/06/21 12:44 AM PST Page 75 of 112 2 Insp ect ankle s Exam Actio n 02/06/21 12:44 AM PST Inspe ct feet Exam Action 02/06/21 12:44 AM PST Page 76 of 112 2 Check ed ID band Exam Action 02/06/21 12:46 AM PST Auscultat ed breath sounds Exam Action 02/06/21 12:46 AM PST Page 77 of 112 2 Confirm ed orientat ion Exam Action 02/06/21 12:48 AM PST What is your name and date of birth? Question 02/06/21 12:48 AM PST I’m Damien Brooks. It’s . . . Page 80 of 112 2 [Mr. Brooks reports his correct date of birth.] What building are you now? Question 02/06/21 12:48 AM PST We’re at Dr. Pulaski’s office, right? Page 81 of 112 2 what is the date and year Question 02/06/21 12:49 AM PST Today? It’s . . .[Mr. Brooks reports the correct date.] Do you know what’s going on? Question 02/06/21 12:50 AM PST Page 82 of 112 2 Burger, tulip, nose, tea. how did you celebrate your birthday? Question 02/06/21 12:51 AM PST My birthday? Oh, this year it was actually pretty sick. The squad threw a surprise party for me. They like ambushed me the morning of, had a cake and candles and everything for me right there in bed. The day just went Page 85 of 112 2 from there. It was a good start to 15, yeah. repeat the four words from before Question 02/06/21 12:52 AM PST Burger . . . nose? Tea? Vocab ulary Exam Action 02/06/21 12:52 AM PST Page 86 of 112 2 Asses sed speec h Exam Action 02/06/21 12:53 AM PST Page 87 of 112 2 run your right foot down your shin Question 02/06/21 12:54 AM PST Page 90 of 112 2 Sure. Observed right heel moving to shin smooth and accurate Exam Action 02/06/21 12:54 AM PST run your left foot down your right shin Question 02/06/21 12:55 AM PST Page 91 of 112 2 Ok. Observed left heel moving to shin smooth and accurate Exam Action 02/06/21 12:55 AM PST place your hands on your knees and turn them over Question 02/06/21 12:55 AM PST Page 92 of 112 2 Damien’s best verbal response Exam Action 02/06/21 12:56 AM PST Measured Damien’s best motor response Exam Action 02/06/21 12:56 AM PST Determined Damien’s Page 95 of 112 2 Glasgow Coma Score Exam Action 02/06/21 12:57 AM PST Page 96 of 112 2 Tested ROM of elbows – supination and pronation Exam Action 02/06/21 12:57 AM PST Tested ROM of elbows – flexion and extension Exam Action 02/06/21 12:57 AM PST Tested ROM of wrists – Page 97 of 112