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! 1 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 hospital? Question 02/05/21 10:43 PM PST Page 1 of 45 1 I banged my head up pretty bad and got this big bump. Tim took me to the ER after I threw up. I know puking is a bad sign. Can confirm it’s also a bad time. Sorry about the bump and the pain Empathize 02/05/21 10:44 PM PST Thanks. How did you sustain the bump? (No matching questions found.) Question 02/05/21 10:44 PM PST What happened? Question 02/05/21 10:44 PM PST I’m not really sure, to be honest. I understa Page 2 of 45 1 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 5 of 45 1 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 6 of 45 1 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 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 ringing in my ears.) Do you have memory problems? Page 7 of 45 1 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 10 of 45 1 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 11 of 45 1 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 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 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 12 of 45 1 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 15 of 45 1 Page 16 of 45 1 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 worse? Question 02/05/21 11:52 PM PST I’m not sure what all can make his pain worse right now. I know he’s said that light hurts his eyes. [AUDIO COMING SOON] Okay. i understand Empathize 02/05/21 11:53 PM PST Well, that’s kind of you to say. Has your son received all vaccinations? (No matching questions found.) Question 02/05/21 11:53 PM PST Page 17 of 45 1 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 20 of 45 1 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 21 of 45 1 Has your son’s speech changed? (No matching questions found.) Question 02/06/21 12:01 AM PST Is he able to follow instructions? Question 02/06/21 12:01 AM PST He’s been walking fine. [AUDIO COMING SOON] Does he have confusion? (No matching questions found.) Question 02/06/21 12:02 AM PST Has your son had confusion? Question 02/06/21 12:02 AM PST I didn’t give him anything at home, but they gave him some medication when we got here — acetaminophen, I think. Does your son have movement problem? (No matching questions found.) Question 02/06/21 12:02 AM PST Page 22 of 45 1 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 25 of 45 1 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 26 of 45 1 shoulder Exam Action 02/06/21 12:14 AM PST Page 27 of 45 1 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 30 of 45 1 Inspect lower legs Exam Action 02/06/21 12:44 AM PST Page 31 of 45 1 Inspect ankles Exam Action 02/06/21 12:44 AM PST Inspect feet Exam Action 02/06/21 12:44 AM PST Checked ID band Exam Action 02/06/21 12:46 AM PST Auscultated breath sounds Exam Action 02/06/21 12:46 AM PST Auscultated heart sounds Exam Action 02/06/21 12:46 AM PST Page 32 of 45 1 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 35 of 45 1 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 36 of 45 1 Assessed speech Exam Action 02/06/21 12:53 AM PST close your eyes and touch your fingers to your nose Question 02/06/21 12:54 AM PST I can do that. Observed left index finger to nose smooth and accurate Exam Action 02/06/21 12:54 AM PST Observed right index finger to nose smooth and accurate Exam Action 02/06/21 12:54 AM PST run your right foot down your shin Question 02/06/21 12:54 AM PST Page 37 of 45 1 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 40 of 45 1 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 41 of 45 1 Tested ROM of ankles – inversion and eversion Exam Action 02/06/21 1:00 AM PST Tested ROM of ankles – dorsiflexion and plantar flexion Exam Action 02/06/21 1:00 AM PST Tested right and left hand strength with grip test: 5/5 Exam Action 02/06/21 1:01 AM PST Strength test feet Exam Action 02/06/21 1:02 AM PST Tested left arm distal sensation Exam Action 02/06/21 1:03 AM PST Tested left arm proximal sensation Exam Action 02/06/21 1:03 AM PST Page 42 of 45