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Case Study 3 October 2008
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Case Study 3 October 2008

The Setting:  You and your WFR trained co-instructor are leading a group of high school students into the mountains for a week long spring break backpacking trip.  A half-mile from the road head you see a lone horse and rider come down the main trail.  Suddenly the horse begins to rear and buck and the rider falls off the back of the horse and lands on his head and shoulder. The weather is warm and sunny.


SOAP Report

Subjective/Summary/Story:

The patient is a 45 yr old male who fell off the back of his rearing horse landing on his head and left shoulder.   He was not trampled by the horse. The patient’s chief complaint is a dull headache he rates as a 4 on a scale of 1-10.  The headache began shortly after his fall.

Objective/Observations/Findings:

The patient was found lying on his back on the trail.   Initially the patient was not awake, but was responsive (he moaned) to a verbal stimulus. Shortly thereafter he began to wake-up and within one to two minutes he became A+OX4.

Patient Exam:

Patient has a golf ball sized bruise/swelling on the back of his head and a 3” bruise on his left shoulder. The patient is moving his arms and legs, denies pain on palpation of the spine and has good circulation, sensation and motion (CSM) in all 4 extremities.  No other injuries found.      

Vital Signs:

TIME  10:15AM  10:45AM
LOC Responsive to verbal stimulus A+Ox4
HR 84, strong, regular 72, strong, regular
RR 12, regular, easy 12, regular, easy
SCTM Pale, Warm, Dry Pink, Warm, Dry
Pupils PERRL PERRL
Temp not taken not taken

History:

Symptoms: Patient states he has a headache and is slightly nauseous.

Allergies: Patient is allergic to peanuts with no recent exposure.                 

Medications: Patient takes a medication for high blood pressure. He took his normal dose today.           

Pertinent Medical History: High Blood Pressure.  Peanut Allergy.                        

Last intake/output: Patient reports he drank a liter of water this morning, ate breakfast and had a normal bowel movement. He vomited once shortly after the accident.

Events relevant to the incident/illness:  None

What is your Assessment and Plan? 



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