NURS 2209B Damien Brooks Transcript Case Study, Exams of Nursing

Download NURS 2209B Damien Brooks Transcript Case Study and more Exams Nursing in PDF only on Docsity! 21 Damien Brooks Transcript Hello, I am xxx. I will be interviewing you today and later perform a physical examination Greet 02/05/21 10:42 PM PST Hey. What is your name? Question 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] Okay Empathi ze 02/05/21 10:43 PM PST Thanks, Nurse. What brought you into the Page 1 of 46 21 hospital? Question 02/05/21 10:43 PM PST Page 2 of 46 21 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.) Do you have a headache? Question 02/05/21 10:45 PM PST Yeah, I definitely have a headache. It hurts to look at light, even. [AUDIO COMING SOON] Do you normally wear sport safety gear? (Clarified to Do you usually wear a helmet?.) Question 02/05/21 11:03 PM PST Not usually, but we’ll practice with them on sometimes. (Clarified to if I usually wear a helmet.) Page 5 of 46 21 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 02/05/21 11:04 PM PST Ok, I’ll keep it in mind. Do you take alcohol? Question 02/05/21 11:04 PM PST No, officer. Do you take illegal drugs? Question 02/05/21 11:04 PM PST Page 6 of 46 21 Nah. Not into it. Do you smoke tobacco? Question 02/05/21 11:05 PM PST That doesn’t really fit with my brand. That is good. Smoking, alcohol and drugs are bad for your health Educate 02/05/21 11:05 PM PST Sure, yeah. Do you have changes in vision? (Clarified to Has your vision changed since the accident?.) Question 02/05/21 11:08 PM PST I can see just fine, my eyes just feel a little light sensitive. (Clarified to if my vision has changed since the accident.) Page 7 of 46 21 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 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, which we’re going to have to chat about later . . . (Clarified to to tell you what happened to my son.) Yeah, it is good to have a helmet Page 10 of 46 21 Educate 02/05/21 11:14 PM PST Thanks, yeah, I’ll remember that. Did you notice any headache for your son? (No matching questions found.) Question 02/05/21 11:17 PM PST Does he have a headache? 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 dizziness? Question 02/05/21 11:17 PM PST Page 11 of 46 21 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 02/05/21 11:19 PM PST Did he have scalp hematoma? (No matching questions found.) Question 02/05/21 11:19 PM PST Did you notice any blood Question 02/05/21 11:19 PM PST I didn’t notice any bleeding. [AUDIO COMING SOON] Page 12 of 46 21 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?.) Question 02/05/21 11:29 PM PST 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.) When did the fall occur? Page 15 of 46 21 Question 02/05/21 11:30 PM PST Damien fell about two hours ago. Describe the mechanism of the injury? (No matching questions found.) Question 02/05/21 11:30 PM PST how did your son fall? Question 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 consciousness? Question 02/05/21 11:34 PM PST Yeah, the fall knocked Damien unconscious. Page 16 of 46 21 Page 17 of 46 21 Question 02/05/21 11:56 PM PST Damien doesn’t have any previous head injuries. (Clarified to what my sons past head injuries are.) Has your son had any surgery? Question 02/05/21 11:56 PM PST Damien’s never had surgery. What home medication does your son use? (No matching questions found.) Question 02/05/21 11:56 PM PST Any home medications? (No matching questions found.) Question 02/05/21 11:57 PM PST what medications is your son using? Question 02/05/21 11:57 PM PST Page 20 of 46 21 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 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 Does your son have headache? Question 02/05/21 11:59 PM PST Page 21 of 46 21 Yes, Damien’s had a headache since he got home. Does he have vision issues? Question 02/06/21 12:00 AM PST Damien’s only mentioned the light sensitivity. [AUDIO COMING SOON] Any ear problem? (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 02/06/21 12:00 AM PST Page 22 of 46 02/06/21 12:12 AM PST Page 25 of 46 21 x 21 Inspected left eye Exam Action 02/06/21 12:13 AM PST Inspected right eye Exam Action 02/06/21 12:13 AM PST Inspect e o m Exam Action 02/06/21 12:13 AM PST Inspect shoulders Exam Action 02/06/21 12:14 AM PST Inspected left shoulder Exam Action 02/06/21 12:14 AM PST Page 26 of 46 21 Inspected upper back Exam Action 02/06/21 12:14 AM PST Inspected right shoulder Exam Action 02/06/21 12:14 AM PST Inspected shoulders from the front Exam Action 02/06/21 12:14 AM PST Inspected right shoulder Exam Action 02/06/21 12:14 AM PST Inspected upper back Exam Action 02/06/21 12:14 AM PST Inspected left Page 27 of 46 02/06/21 12:16 AM PST Page 30 of 46 21 x 21 Inspected both hands Exam Action 02/06/21 12:17 AM PST Inspect hips Exam Action 02/06/21 12:17 AM PST Inspect thighs Exam Action 02/06/21 12:18 AM PST Inspect thighs Exam Action 02/06/21 12:19 AM PST Inspect knees Exam Action 02/06/21 12:43 AM PST Page 31 of 46 21 Inspect lower legs Exam Action 02/06/21 12:44 AM PST Page 32 of 46 21 We’re at Dr. Pulaski’s office, right? Page 35 of 46 21 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 Wiped out on my board and knocked my head, which ended me up here. It’s pretty messed up. Assessed cognition Exam Action 02/06/21 12:50 AM PST repeat and remember burger, tulip, nose and tea Question 02/06/21 12:51 AM PST Page 36 of 46 21 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 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? Vocabulary Exam Action 02/06/21 12:52 AM PST Assessed speech Exam Action 02/06/21 12:53 AM PST Page 37 of 46 21 Observed rapid alternating hand movements Exam Action 02/06/21 12:55 AM PST Eye Opening Response measured as “spontaneously “ Exam Action 02/06/21 12:56 AM PST Measured 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 Glasgow Coma Score Exam Action 02/06/21 12:57 AM PST Page 40 of 46 21 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 – flexion Exam Action 02/06/21 12:58 AM PST Tested ROM of wrists – extension Exam Action 02/06/21 12:58 AM PST Tested ROM of wrists – ulnar and radial deviation Exam Action 02/06/21 12:58 AM PST Tested ROM of hips – flexion Exam Action 02/06/21 12:59 AM PST Page 41 of 46 21 Tested ROM of hips – extension Exam Action 02/06/21 12:59 AM PST Tested ROM of hips – abduction Exam Action 02/06/21 12:59 AM PST Tested ROM of hips – adduction Exam Action 02/06/21 12:59 AM PST Tested ROM of knees – flexion Exam Action 02/06/21 1:00 AM PST Tested ROM of knees – extension Exam Action 02/06/21 1:00 AM PST Page 42 of 46 21 Yeah. Tested left leg proximal sensation Exam Action 02/06/21 1:04 AM PST Yeah. Tested right leg proximal sensation Exam Action 02/06/21 1:04 AM PST Yeah. Tested right leg distal sensation Exam Action 02/06/21 1:04 AM PST Yeah. Page 45 of 46 21 Tested sensation of left foot Exam Action 02/06/21 1:05 AM PST Yeah. Tested sensation of right foot Exam Action 02/06/21 1:05 AM PST Palpated cap refill Exam Action 02/06/21 1:06 AM PST Reflex hammer patellar mode Exam Action 02/06/21 1:06 AM PST Reflex hammer brachioradialis mode Exam Action 02/06/21 1:06 AM PST Page 46 of 46