Sunday, 21 December 2014
rendezvous - Beta 0.3
Case Study 8 October 2008
Article Index
Case Study 8 October 2008

The Setting

You have been participating in the annual Yellowstone Ski Festival, in West Yellowstone, MT. This event happens every year over Thanksgiving and provides an opportunity for you to get up on your Nordic skis before most other places in the West. The date is Sunday, November 25th. The festival is over. You and your party are packing up to head home.

SOAP Report

Subjective/Summary/Story
The patient, a member of your entourage, is a 40 year old male who is complaining of dull, achy pain and limited range of motion localized around his left elbow. The pain began on Friday evening, the 23rd, after two days of hard skate skiing. The first of his season. The pain is currently a 5-6 on a 1-10 scale. The elbow is very tender. Pain spikes to a 9 when it is bumped.

Objective/Observation/Findings

  Patient is uncomfortable from the pain and is unable to move his arm through his full range of motion. Patient states “I must have tweaked my elbow over the last couple of days and developed some acute bursitis.”

Patient Exam:
The left elbow is noticeably red and swollen. Swelling seems to extend several inches both distal and proximal to the elbow.
 

Vital Signs
TIME

0800 hrs, Nov 25

0800 hrs, Nov 26

LOR

A+OX4

A+OX4

HR

84, strong, regular

86, strong regular (High for this patient. Normally 50-60)

RR

16, regular, easy

16, regular, easy

SCTM

Pale, Warm, Dry

Pale, Warm, Dry

B.P.

Not taken

Not taken

Pupils

PERRL

PERRL

Not taken

100°F oral

 

History

Symptoms:

Patient is uncomfortable and fatigued

Allergies:

None stated

Medications:

Patient began taking 400 mg of ibuprofen every 4-6 hours for pain beginning at 0800 hrs on 11/24.

Pertinent Hx:

Patient denies any similar history. Patient states he has a history of elbow tendonitis and of small lesions on his elbow the week before related to some “eczema-like bumps” he has gotten on/off since childhood.

Last in/out:

Patient has been well hydrated and his appetite has been good.  Reports normal bowel function.  Patient urinated clear urine this morning. 

Events:

Patient skate skied hard for the first time this season on Nov22 and 23.  Pain began evening of Nov23. Patient participated in a ski clinic on Nov24 and the elbow remained sore with limited range of motion throughout the day.


What is your Assessment and Plan?  



< Previous   Next >
Check out more photos like this one in The NOLS Photo Group at www.flickr.com

Login/Logout
User Menu

 


Home Locations Departments Faculty News and Reports Help Home Dream Sheet Blog New Employee ProDeals Who's who? Message Board Links Admission & Marketing Alumni & Development Curriculum Finance, Purchasing & Mailroom Human Resources Information Systems NOLS Professional Training Operations Public Policy Risk Management Wilderness Medicine Institute Grading Notebooks Staffing WMI Links Newsletters Managers' Notes EDT Forum Board Reports Help Desk FAQ NOLS Home About Us Courses Wilderness Medicine Institute NOLS Professional Training Alumni Store Donate Account NOLS Home About Us Courses Wilderness Medicine Institute NOLS Professional Training Alumni Store Donate Account WMI Home About WMI Courses Schedule FAQ Photos & Movies Curriculum Updates Employment Sponsors Find a Course Skills Financial Aid College Credit Photos and Movies NOLS Home About Us Courses Wilderness Medicine Institute NOLS Professional Training Alumni Store Donate Account Photos & Videos Home NOLS Photos NOLS.TV The NOLS Podcast NOLS on Flickr WMI Home About WMI Admissions Courses Schedule Host a Course Resources Gallery