Rachel Adler Alcohol Use Disorder Shadow Health Transcript Transcript

Rachel Adler Alcohol Use Disorder Shadow Health Transcript
Transcript

Hello. My name is xxx, and I will be conducting an interview with you and performing a physical examination.

Greet
June 16, 2022, 10:13 PM EDT
Rachel Adler.
Hi. Thank you for being here.

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What brings you here today?

Question
June 16, 2022, 10:17 PM EDT
Rachel Adler.
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 sustain an injury?

Question
June 16, 2022, 10:18 PM EDT
Rachel Adler.
Other than my wrist? No, I don’t think so.

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Have you ever attempted suicide?

Question
June 16, 2022, 10:22 PM EDT
Rachel Adler.
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 from feeling so sick and tired of everything.

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Did you lose consciousness?

Question
June 16, 2022, 10:30 PM EDT
Rachel Adler.
I passed out in the car crash. I don’t remember how it happened.

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Were you wearing a seatbelt?

Question
June 16, 2022, 10:34 PM EDT
Rachel Adler.
I always wear my seatbelt. Even when I’m drunk driving, apparently.

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Did you consume alcohol before the accident?

Question
June 16, 2022, 10:34 PM EDT
Rachel Adler.
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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Were you driving cautiously?

Question
June 16, 2022, 10:35 PM EDT
Rachel Adler.
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?

Question
June 16, 2022, 10:36 PM EDT
Rachel Adler.
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?

Question
June 16, 2022, 10:37 PM EDT
Rachel Adler.
My wrist hurts the most. The right one, in the brace.

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What exacerbates your pain?

Question
June 16, 2022, 10:37 PM EDT
Rachel Adler.
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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I’m sorry to hear that.

Empathize
June 16, 2022, 10:38 PM EDT
Rachel Adler.
Ha, thanks.

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What provides relief from your pain?

Question
June 16, 2022, 10:38 PM EDT
Rachel Adler.
The ibuprofen has helped with the pain. That, and the sling.

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Does resting improve your pain?

Question
June 16, 2022, 10:39 PM EDT
Rachel Adler.
Yeah, resting here does help.

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How would you describe your pain?

Question
June 16, 2022, 10:40 PM EDT
Rachel Adler.
It’s kind of this constant ache.

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Do you experience any sharp pain?

Question
June 16, 2022, 10:40 PM EDT
Rachel Adler.
No, I wouldn’t describe it that way. It’s more of an ache.

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On a scale of 1 to 10, with 10 being the worst, how would you rate your pain?

Question
June 16, 2022, 10:40 PM EDT
Rachel Adler.
I’d say my pain is about a two out of ten.

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Does your medication alleviate the pain?

Question
June 16, 2022, 10:41 PM EDT
Rachel Adler.
The ibuprofen has helped with the pain. That, and the sling.

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Do you have any other medical conditions?

Question
June 16, 2022, 10:42 PM EDT
Rachel Adler.
I don’t have any illnesses.

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Have you ever been diagnosed with a mental disorder?

Question
June 16, 2022, 10:42 PM EDT
Rachel Adler.
I’ve never been diagnosed with a mental illness.

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Any history of depression?

Question
June 16, 2022, 11:14 PM EDT
Rachel Adler.
No, no one’s ever told me I have depression.

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Have you been experiencing stress?

Question
June 16, 2022, 11:15 PM EDT
Rachel Adler.
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, deal with my parents, and 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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I’m sorry to hear that.

Empathize
June 16, 2022, 11:16 PM EDT
Rachel Adler.
Thanks. I wish I were kind to myself like that.

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Have you had any thoughts of suicide?

Question
June 16, 2022, 11:17 PM EDT
Rachel Adler.
I don’t have a plan, if that’s what you mean. Before last night, I didn’t want to end my life. 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?

Question
June 16, 2022, 11:17 PM EDT
Rachel Adler.
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 from feeling so sick and tired of everything.

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Do you feel uncertain about your life?

Question
June 16, 2022, 11:18 PM EDT
Rachel Adler.
I don’t know. I haven’t contemplated physically ending my life or how I would do it or anything. It’s more about wishing not to be here. It would be so much simpler.

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I’m sorry to hear that.

Empathize
June 17, 2022, 12:

40 AM EDT
Rachel Adler.
Thanks for understanding.

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Why do you wish you had died in the car accident?

Question
June 17, 2022, 12:43 AM EDT
Rachel Adler.
Well, it would be so much better if I didn’t have to endure 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…

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What makes you contemplate death?

Question
June 17, 2022, 12:45 AM EDT
Rachel Adler.
Well, it would be so much better if I didn’t have to endure 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…

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I’m sorry to hear that.

Empathize
June 17, 2022, 12:40 AM EDT
Rachel Adler.
Thanks. I wish I were kind to myself like that.

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Assess vital signs

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the right eye

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the left eye

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the right eye

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the left eye

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the left arm

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the right arm: the right hand appears normal, the right wrist shows redness and swelling

Exam Action
June 17, 2022, 12:40 AM EDT
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Inspect the left arm: no visible abnormalities

Exam Action
June 17, 2022, 12:41 AM EDT
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Inspect the left wrist: no visible abnormalities

Exam Action
June 17, 2022, 12:41 AM EDT
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Inspect the left hand: no visible abnormalities

Exam Action
June 17, 2022, 12:41 AM EDT
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Inspect the right arm: no visible abnormalities

Exam Action
June 17, 2022, 12:42 AM EDT
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Inspect the right wrist: no visible abnormalities

Exam Action
June 17, 2022, 12:42 AM EDT
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Inspect the right hand: no visible abnormalities

Exam Action
June 17, 2022, 12:42 AM EDT
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Inspect the left arm: no visible abnormalities

Exam Action
June 17, 2022, 12:43 AM EDT
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Auscultate breath sounds

Exam Action
June 17, 2022, 12:44 AM EDT
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Auscultate heart sounds

Exam Action
June 17, 2022, 12:44 AM EDT
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Palpate radial arteries

Exam Action
June 17, 2022, 12:44 AM EDT
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Test capillary refill

Exam Action
June 17, 2022, 12:44 AM EDT
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Assess general appearance: indirect eye contact, tension and rigidity, clean clothing, and appropriate level of grooming

Exam Action
June 17, 2022, 12:45 AM EDT
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Assess attitude: suspicious, guarded, or evasive

Exam Action
June 17, 2022, 12:45 AM EDT
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Assess speech: expected rate of speech, loud speech volume, and no appreciable issues with articulation

Exam Action
June 17, 2022, 12:45 AM EDT
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Assess mood and affect: stable mood and a balanced affect

Sick Visit: Integumentary Felipe Barbosa Shadow Health Treatment Plan

Exam Action
June 17, 2022, 12:45 AM EDT
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Assess thought process: no presence of thought disturbances

Exam Action
June 17, 2022, 12:46 AM EDT
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Assess thought content: mentions suicidal ideation but no perceptual disturbances

Exam Action
June 17, 2022, 12:46 AM EDT
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Confirm orientation

Exam Action
June 17, 2022, 12:46 AM EDT
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What is your name and date of birth?

Question
June 17, 2022, 12:46 AM EDT
Rachel Adler.
Rachel Adler, and I was born… [Ms. Adler provides her correct date of birth.]

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In which building are you currently?

Question
June 17, 2022, 12:47 AM EDT
Rachel Adler.
We’re in Shadow General Hospital.

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Can you tell me the date and year?

Question
June 17, 2022, 12:47 AM EDT
Rachel Adler.
Yeah, it’s… [Ms. Adler provides the correct date and year.]

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Assess cognition

Exam Action
June 17, 2022, 12:48 AM EDT
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Count backward from 100 by 7 until you reach the 60s.

Question
June 17, 2022, 12:49 AM EDT
Rachel Adler.
Uh, sure… 100, 93, 86, 79… (Ms. Adler completes the sequence)

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Assess cognition

Exam Action
June 17, 2022, 12:49 AM EDT
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How are apples and oranges similar?

Question
June 17, 2022, 12:49 AM EDT
Rachel Adler.
Those are both types of fruit.

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How are a lake and an ocean similar?

Question
June 17, 2022, 12:50 AM EDT
Rachel Adler.
Obviously, those are both bodies of water.

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How are a trumpet and a flute similar?

Question
June 17, 2022, 12:50 AM EDT
Rachel Adler.
Those are both instruments. Wind instruments.

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Assess cognition

Exam Action
June 17, 2022, 12:50 AM EDT
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Repeat and remember the words “burger, tulip, nose, and tea.”

Question
June 17, 2022, 12:51 AM EDT
Rachel Adler.
Burger, tulip, nose, tea. Got it.

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How did you celebrate your last birthday?

Question
June 17, 2022, 12

:51 AM EDT
Rachel Adler.
It was pretty low-key, actually. I went to dinner with some friends, and then we watched movies at my place. It was nice.

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Repeat the four words from earlier.

Question
June 17, 2022, 12:52 AM EDT
Rachel Adler.
Burger, tulip, nose, and tea.

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Copy the shapes exactly as you see them.

Question
June 17, 2022, 12:52 AM EDT
Rachel Adler.
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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Assess insight: demonstrates limited or no awareness of illness and/or is unwilling to seek treatment

Exam Action
June 17, 2022, 12:53 AM EDT
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Assess judgment: demonstrates good judgment

Exam Action
June 17, 2022, 12:53 AM EDT
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What would you do if you found a stamped envelope on the sidewalk?

Question
June 17, 2022, 12:54 AM EDT
Rachel Adler.
Uh, I guess I’d try to drop it in a postbox somewhere.