Damien Brooks Transcript -Traumatic Brain Injury- Shadow Health, Exams of Nursing

Download Damien Brooks Transcript -Traumatic Brain Injury- Shadow Health and more Exams Nursing in PDF only on Docsity! Damien uBrooks uTranscript Hello, uI uam uxxx. uI uwill ube uinterviewing uyou utoday uand ulater uperform ua uphysical uexamination Greet 02/05/21 u10:42 uPM uPST Hey. What uis uyour uname? uQuestion 02/05/21 u10:43 uPM uPST Damien uBrooks uand umy ubirthday uis uJuly u25th, uif uyou uwant uto uget ume uanything. u[AUDIO uCOMING uSOON] Okay uEmpathiz e 02/05/21 u10:43 uPM uPST Thanks, uNurse. What ubrought uyou uinto uthe uhospital? uQuestion 02/05/21 u10:43 uPM uPST I ubanged umy uhead uup upretty ubad uand ugot uthis ubig ubump. uTim utook ume uto uthe uER uafter uI uthrew uup. uI uknow upuking uis ua ubad usign. uCan uconfirm uit’s ualso ua ubad utime. Sorry uabout uthe ubump uand uthe upain uEmpathize 02/05/21 u10:44 uPM uPST Thanks. How udid uyou usustain uthe ubump? u(No umatching uquestions ufound.) uQuestion 02/05/21 u10:44 uPM uPST What uhappened? uQuestion 02/05/21 u10:44 uPM uPST I’m unot ureally usure, uto ube uhonest. I uunderstand uEmpathize 02/05/21 u10:44 uPM uPST Nah. uNot uinto uit. Do uyou usmoke utobacco? uQuestion 02/05/21 u11:05 uPM uPST That udoesn’t ureally ufit uwith umy ubrand. That uis ugood. uSmoking, ualcohol uand udrugs uare ubad ufor uyour uhealth uEducate 02/05/21 u11:05 uPM uPST Sure, uyeah. Do uyou uhave uchanges uin uvision? u(Clarified uto uHas uyour uvision uchanged usince uthe uaccident?.) Question 02/05/21 u11:08 uPM uPST I ucan usee ujust ufine, umy ueyes ujust ufeel ua ulittle ulight usensitive. u(Clarified uto uif umy uvision uhas uchanged usince uthe uaccident.) Do uyou uhave udifficulties umoving uyour uextremities? u(Clarified uto uAre uyou uhaving uany uissues umoving uyour ulegs?.) Question 02/05/21 u11:08 uPM uPST I’m unot ufeeling uawesome uright unow, ubut uI ucan umove uaround uokay. u(Clarified uto uif uI uhave udifficulty umoving umy ulegs.) Do uyou uhave uany utingling? uQuestion 02/05/21 u11:09 uPM uPST No, uno utingling uor uanything. Do uyou uhave uear uproblem? u(Clarified uto uDo uyou uhave uringing uin uyour uears?.) uQuestion 02/05/21 u11:09 uPM uPST No, uI udon’t uhave uany uringing uin umy uears. u[AUDIO uCOMING uSOON] u(Clarified uto uif uI uhave uringing uin umy uears.) Do uyou uhave umemory uproblems? Question 02/05/21 u11:10 uPM uPST Yeah, uthe uwhole uwipe uout uis ua ublur. uKinda umessed uup unot ubeing uable uto uremember ustuff. Do uyou uhave uneck upain? uQuestion 02/05/21 u11:10 uPM uPST My uneck uis ufine. do uyou uhave umuscle uweakness? uQuestion 02/05/21 u11:10 uPM uPST I’d usay uI’m upretty ustrong. Do uyou uhave umuscle uspasms? uQuestion 02/05/21 u11:11 uPM uPST Haven’t uhad uany umuscle uspasms. I udidn’t ugive uhim uanything uat uhome, ubut uthey ugave uhim usome umedication uwhen uwe ugot uhere u— uacetaminophen, uI uthink. Did uhe uhave uconfusion? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:18 uPM uPST Did uyour uson uhave uscalp uhematoma? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:19 uPM uPST Did uhe uhave uscalp uhematoma? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:19 uPM uPST Did uyou unotice uany ublood uQuestion 02/05/21 u11:19 uPM uPST I udidn’t unotice uany ubleeding. u[AUDIO uCOMING uSOON] Is uyour uson uson ucomplaining uof ulight usensitivity? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:20 uPM uPST Is uyour uson ucomplaining uof ulight usensitivity? u(Clarified uto uHas uyour uson ubeen usensitive uto ulight?.) Question 02/05/21 u11:20 uPM uPST Yes, udefinitely. u(Clarified uto uif umy uson uhas ubeen usensitive uto ulight.) Did uhe ureport uvomiting? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:21 uPM uPST Did uhe uhave uany uvomiting? u(Clarified uto uHas uyour uson uvomited?.) uQuestion 02/05/21 u11:21 uPM uPST It uwas uafter uDamien ucame uhome uand utold ume uhe uhad ufallen. uHe uwas ufeeling udizzy uand uhad ua uheadache. uHe uthrew uup upretty usoon uafter uthat, uand uthat’s uwhen uI udecided uto udrive uhim uover uhere. u(Clarified uto uif umy uson uhas uvomited.) Did uyou unotice uany uother uadditional usymptoms? u(Clarified uto uHave uyou unoticed uany uother uinjuries uon uyour uson?.) Question 02/05/21 u11:23 uPM uPST I uhaven’t unoticed uany uother uinjuries uon uDamien uother uthan uthe uwelt uon uhis uhead. u(Clarified uto uif uI uhave unoticed uany uother uinjuries uon umy uson.) Describe uthe uonset uof uthe usymptoms? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:26 uPM uPST Describe uthe uonset uof uthe uhead uinjury u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:26 uPM uPST what uis uthe uduration uof uthe upain? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:27 uPM uPST How ufrequent uis uthe uheadache? u(No umatching uquestions ufound.) What uare urelieving ufactors ufor uthe upain? uQuestion 02/05/21 u11:52 uPM uPST I ugave uhim uan uice upack uand ulaid uhim udown uon uthe ucouch. uI utried udimming uthe ulights utoo. uBut uonce uhe uthrew uup, uI udecided uI uwas uout uof umy udepth uand udrove uhim uhere. What umakes uthe upain uworse? uQuestion 02/05/21 u11:52 uPM uPST I’m unot usure uwhat uall ucan umake uhis upain uworse uright unow. uI uknow uhe’s usaid uthat ulight uhurts uhis ueyes. u[AUDIO uCOMING uSOON] Okay. ui u nderstand uEmpathize 02/05/21 u11:53 uPM uPST Well, uthat’s ukind uof uyou uto usay. Has uyour uson ureceived uall uvaccinations? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:53 uPM uPST Has uhe uhad uall uvaccinations? u(Clarified uto uDoes uyour uson uhave uall uhis uvaccines?.) uQuestion 02/05/21 u11:54 uPM uPST Yes, uhe’s ugot uall uhis ushots. u(Clarified uto uif umy uson uis uvaccinated.) That uis ugreat. uVaccinations uare uvery uimportant ufor ugood uhealth uEducate 02/05/21 u11:54 uPM uPST I ugotcha, uloud uand uclear. Has uhe uever ubeen uhospitalized? uQuestion 02/05/21 u11:55 uPM uPST Damien’s unever ubeen uto uthe uhospital ubefore. uWe’re uvery ulucky, uespecially uif uhe uhasn’t ubeen uwearing uhis uhelmet ulike uthis utime. uHe’s udefinitely ufallen uin uthe upast. Has uhe uever uhad uhead uinjury? u(Clarified uto uWhat uprevious uhead uinjuries uhas uyour uson uhad?.) Question 02/05/21 u11:56 uPM uPST Damien udoesn’t uhave uany uprevious uhead uinjuries. u(Clarified uto uwhat umy usons upast uhead uinjuries uare.) Has uyour uson uhad uany usurgery? u u uQuestion 02/05/21 u11:56 uPM uPST Damien’s unever uhad usurgery. What uhome umedication udoes uyour uson uuse? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:56 uPM uPST Any uhome umedications? u(No umatching uquestions ufound.) uQuestion 02/05/21 u11:57 uPM uPST what umedications uis uyour uson uusing? uQuestion 02/05/21 u11:57 uPM uPST Has uyour uson’s uspeech uchanged? u(No umatching uquestions ufound.) uQuestion 02/06/21 u12:01 uAM uPST Is uhe uable uto ufollow uinstructions? uQuestion 02/06/21 u12:01 uAM uPST He’s ubeen uwalking ufine. u[AUDIO uCOMING uSOON] Does uhe uhave uconfusion? u(No umatching uquestions ufound.) uQuestion 02/06/21 u12:02 uAM uPST Has uyour uson uhad uconfusion? uQuestion 02/06/21 u12:02 uAM uPST I udidn’t ugive uhim uanything uat uhome, ubut uthey ugave uhim usome umedication uwhen uwe ugot uhere u— uacetaminophen, uI uthink. Does uyour uson uhave umovement uproblem? u(No umatching uquestions ufound.) uQuestion 02/06/21 u12:02 uAM uPST Does uyour uson uhave uissue uwith umovement? u(Clarified uto uDoes uyour uson uhave uany ubalance uor ugait uissues?.) Question 02/06/21 u12:03 uAM uPST Nope, uhe’s ubeen ugetting uaround ujust ufine. u(Clarified uto uif umy uson uhas uany ubalance uor ugait uissues.) Exam uAction 02/06/21 u12:12 uAM uPST Inspected uhead ufront: uNo uabnormal ufindings uExam uAction 02/06/21 u12:12 uAM uPST Inspected uleft ueye uExam uAction 02/06/21 u12:12 uAM uPST Inspected uright ueye uExam uAction 02/06/21 u12:12 uAM uPST Inspected uleft ueye uExam uAction 02/06/21 u12:13 uAM uPST Inspected uright ueye uExam uAction 02/06/21 u12:13 uAM uPST Inspect ue uo um uExam uAction 02/06/21 u12:13 uAM uPST Inspect ushoulders uExam uAction 02/06/21 u12:14 uAM uPST Inspected uleft ushoulder uExam uAction 02/06/21 u12:14 uAM uPST Inspected uboth uhands uExam uAction 02/06/21 u12:17 uAM uPST Inspect uhips uExam uAction 02/06/21 u12:17 uAM uPST Inspect uthighs uExam uAction 02/06/21 u12:18 uAM uPST Inspect uthighs uExam uAction 02/06/21 u12:19 uAM uPST Inspect uknees uExam uAction 02/06/21 u12:43 uAM uPST Inspect ulower ulegs uExam uAction 02/06/21 u12:44 uAM uPST Inspect uankles uExam uAction 02/06/21 u12:44 uAM uPST Inspect ufeet uExam uAction 02/06/21 u12:44 uAM uPST Checked uID uband uExam uAction 02/06/21 u12:46 uAM uPST Auscultated ubreath usounds uExam uAction 02/06/21 u12:46 uAM uPST Auscultated uheart usounds uExam uAction 02/06/21 u12:46 uAM uPST Auscultated ubreath usounds uExam uAction 02/06/21 u12:47 uAM uPST Palp ucardio upulses uradial uExam uAction 02/06/21 u12:47 uAM uPST Confirmed uorientation uExam uAction 02/06/21 u12:48 uAM uPST What uis uyour uname uand udate uof ubirth? uQuestion 02/06/21 u12:48 uAM uPST I’m uDamien uBrooks. uIt’s u. u. u. u[Mr. uBrooks ureports uhis ucorrect udate uof ubirth.] What ubuilding uare uyou unow? uQuestion 02/06/21 u12:48 uAM uPST We’re uat uDr. uPulaski’s uoffice, uright? Assessed uspeech uExam uAction 02/06/21 u12:53 uAM uPST close uyour ueyes uand utouch uyour ufingers uto uyour unose uQuestion 02/06/21 u12:54 uAM uPST I ucan udo uthat. Observed uleft uindex ufinger uto unose usmooth uand uaccurate uExam uAction 02/06/21 u12:54 uAM uPST Observed uright uindex ufinger uto unose usmooth uand uaccurate uExam uAction 02/06/21 u12:54 uAM uPST run uyour uright ufoot udown uyour ushin uQuestion 02/06/21 u12:54 uAM uPST Sure. Observed uright uheel umoving uto ushin usmooth uand uaccurate uExam uAction 02/06/21 u12:54 uAM uPST run uyour uleft ufoot udown uyour uright ushin uQuestion 02/06/21 u12:55 uAM uPST Ok. Observed uleft uheel umoving uto ushin usmooth uand uaccurate uExam uAction 02/06/21 u12:55 uAM uPST place uyour uhands uon uyour uknees uand uturn uthem uover uQuestion 02/06/21 u12:55 uAM uPST Sounds ugood Observed urapid ualternating uhand umovements uExam uAction 02/06/21 u12:55 uAM uPST Eye uOpening uResponse umeasured uas u“spontaneously u“ uExam uAction 02/06/21 u12:56 uAM uPST Measured uDamien’s ubest uverbal uresponse uExam uAction 02/06/21 u12:56 uAM uPST Measured uDamien’s ubest umotor uresponse uExam uAction 02/06/21 u12:56 uAM uPST Determined uDamien’s uGlasgow uComa uScore uExam uAction 02/06/21 u12:57 uAM uPST Tested uROM uof uankles u– uinversion uand ueversion uExam uAction 02/06/21 u1:00 uAM uPST Tested uROM uof uankles u– udorsiflexion uand uplantar uflexion uExam uAction 02/06/21 u1:00 uAM uPST Tested uright uand uleft uhand ustrength uwith ugrip utest: u5/5 uExam uAction 02/06/21 u1:01 uAM uPST Strength utest ufeet uExam uAction 02/06/21 u1:02 uAM uPST Tested uleft uarm udistal usensation uExam uAction 02/06/21 u1:03 uAM uPST Tested uleft uarm uproximal usensation uExam uAction 02/06/21 u1:03 uAM uPST Yeah. Yeah. Tested uright uarm uproximal usensation uExam uAction 02/06/21 u1:03 uAM uPST Yeah. Tested uright uarm udistal usensation uExam uAction 02/06/21 u1:03 uAM uPST Yeah. Yeah. Tested uleft uleg udistal usensation uExam uAction 02/06/21 u1:04 uAM uPST Yeah. Tested uleft uleg uproximal usensation uExam uAction 02/06/21 u1:04 uAM uPST Yeah. Tested uright uleg uproximal usensation uExam uAction 02/06/21 u1:04 uAM uPST Yeah. Tested uright uleg udistal usensation uExam uAction 02/06/21 u1:04 uAM uPST Yeah.