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Case Study 11 May 2016
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Case Study 11 May 2016
Page 2

The Setting

You’re leading a canoe trip on the Rio Grande River in Big Bend. It’s been hot, with temperatures of 97°F (36°C) day after day and evening lows 70°F (21°C). Today you paddled for a few hours after a long morning hike up a side canyon and now are floating lazily watching a bird. Your observations are interrupted by yells for help downstream. You paddle to a beached canoe and several people on shore. One of your participants shouts that George is having a seizure.  


George is on his back in obvious pain with his legs quivering. His arms seem to be moving appropriately. The other participant is insisting this is a seizure. You’re not so sure. Your scene size-up tells you George is wet, no one is in the water and there are no obvious hazards. You learn these “seizures” started when George was kneeling in the canoe. He fell into the water near shore when he tried to exit the canoe and was not submerged. You don your gloves and do your initial assessment.


SOAP Report

Subjective 

The patient is a 43 yr old with muscle spasms to the legs.


Objective

Patient Exam: The patient is lying on his back, crying out in pain with obvious muscle spasms to his legs (quads, hamstrings, calves (the worst).  He is A+Ox4 and denies losing responsiveness or being submerged in the water.  Head-to-toe exam does not reveal any sign of injury.



Vital Signs

TIME 1625 hrs

LOR A+Ox4

HR 100, strong, regular

RR 28, shallow, unlabored

SCTM pink, warm, sweaty

BP radial pulses present

Pupils PERRL

Not taken


History

Symptoms: Patient complains of dizziness, headache and nausea.

Allergies: None

Medications: Denies OTC, herbal or recreational.  Takes a medication for high blood pressure and is on his normal dosing schedule.

Pertinent Hx: Mild hypertension. Patient states he has felt “lousy” since he woke this morning.  He has never experienced these cramps.

Last in/out: Patient’s hydration status is unclear. He states he had 3 liters of water today and yesterday as well. He did not eat much today due to nausea.  No bowel movement today. Urinated twice today but did not note the color.

Events: Paddling and hiking in hot windy weather the past three days.


What is your Assessment and Plan?  DO NOT click/peek at the next page without answering this first.



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