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Case Study 5 October 2008
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Case Study 5 October 2008

The Setting

You’re the supervisor for several crews doing volunteer trail maintenance in a local national forest. Your crew leaders are new, so you want to keep a close watch on the crews. Plus, it’s a good reason to get out of the office, away from the email, and enjoy a hike in the hills.

The weather has been unusually hot and humid, with daytime temperatures in the 90’s °F ( (30’s °C). You find one of your crews around lunch, resting under a few trees. They look lethargic and tired. The crew boss has one of the crewmembers lying on his back with feet elevated and a wet bandanna on his forehead. You ask if you can help and your crew leaders gives you a SOAP report on the patient.

SOAP Report

Subjective/Summary/Story

The patient is an 19 year old male who complains of weakness, dizziness, heat stress and a headache.

Objective/Observations/Findings

Patient Exam

The patient is supine with feet elevated. He denies falling or any injuries and head to toe exam does not find any sign of injury.

Vital Signs:

TIME 
1215hrs
LOC
A+Ox4
HR
80, strong, regular
RR
20, shallow, unlabored, regular
SCTM
warm, pale, sweaty
BP
Radial pulses present
Pupils
PERRL
Temp
99°F oral

 

History:

Symptoms:
Patient states he feels weak, dizzy and has a headache.
Allergies:
Patient denies allergies.
Medications:
Patient has been taking 200-400 mg ibuprofen daily for minor muscle aches.
Pertinent Hx:
Patient denies any pertinent medical history.
Last in/out:
Patient ate breakfast and states he drank 1.5 liters of water today with some Gatoradeâ mixed in.
Events:
Patient has been working on a trail crew for several days.

 

What is your Assessment and Plan? 




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