Friday, 19 December 2014
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Case Study 4 October 2008
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Case Study 4 October 2008

The Setting:  It’s day 5 of a planned 12 day wilderness trip for teenagers in a western U.S. wilderness area.  The closest road is 12 miles.  The weather is warm and dry and not a factor in this scenario.   You’re one of the trip leaders with current WFR training.  The patient is one of your participants.  It is 8:30AM.

SOAP Report

Subjective/Story/Summary:

The patient is a 17 yr old male who is complaining of severe abdominal pain. The patient’s tentmates woke us at 6:30AM and said the patient had severe belly pain.  Patient states the pain began yesterday at 10:00AM as “a bad belly ache cramping-like” but is now “sharp”. He thought it was indigestion.  It persisted all night and became “really uncomfortable” about 10:00PM last night.  The pain is across the lower abdominal quadrants, does not radiate and is presently an 8 on a 1-10 scale. 

Objective/Observations/Findings:

Patient is obviously uncomfortable from the pain.  Patient states the pain is worse when he walks, especially when he walks down hill or hops.  

Patient Exam: There is no point tenderness or rebound pain.  No signs of injury or rigidity to the belly.

Vital Signs:

TIME  6:45AM  7:15AM 8:00AM
LOC AOX4 AOX4 AOX4
HR 84, strong, regular 84, strong, regular 84, strong, regular
RR 16, regular, easy 16, regular, easy 16, regular, easy
SCTM Pale, Warm, Dry Pale, Warm, Dry Pale, Warm, Dry
BP not taken not taken not taken
Pupils PERRL PERRL PERRL
Temp 99°F oral 99°F oral 99°F oral

History:

Symptoms: Patient is nauseous. No other complaints.
Allergies: Patient denies any allergies.
Medications: Patient denies any medications.
Pertinent medical history: Patient denies any history of abdominal problems.
Last intake/output: Patient has been well hydrated and denies diarrhea. He ate very little for dinner last night.  Reports normal bowel movement yesterday, no bowel movement yet today.  Patient urinated clear urine this morning.  He drank one cup of water this morning.
Events relevant to the incident/illness:  Patient’s tentmates are not ill.  They say the patient moaned from the pain all night long, but did not want to wake up the leaders.  The patient denies a blow to the abdomen.

What is your Assessment and Plan? 



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