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Case Study 12 September 2009
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Case Study 12 September 2009
Page 2

The Setting

You’re working out of a remote ranch on the sagebrush plains of southern Idaho.  It’s early May and several of you ride and walk daily to survey herds of pronghorn as part of a research program and a masters thesis.  One of your classmates goes to bed feeling lousy and wakes up feeling worse.  Knowing you have training as a Wilderness First Responder (WFR), you’re asked to take a look at this poor fellow.

 

SOAP Report

Subjective

The patient is a 21 yr old male complaining of a headache, nausea, muscle aches, fever and chills.  These symptoms began yesterday and have persisted through the night.

 

Objective

Patient Exam

The patient is in his sleeping bag in the bunkhouse.  He denies recent injury.

 

Vital Signs

 

TIME

6:30 a.m.

LOR

A+Ox4

HR

72, strong, regular

RR

14, regular, easy

SCTM

Pale, warm, dry

BP

Radial pulses present

Pupils

PERRL

101°F (38.3°C)

 

History

 

Symptoms:

Dull headache, nausea, muscle aches, loss of energy and appetite.  No diarrhea, vomiting, sore throat, neck stiffness, shortness of breath, cough or sinus congestion. These symptoms began yesterday and have persisted through the night. No known cause.  Other group members are not experiencing these symptoms.

Allergies:

Patient thinks he may be allergic to “cillin” antibiotics but does not remember a specific event causing this concern.

Medications:

Patient is not on any regular medications.  For this illness he has been taking ibuprofen 400 mg every 4 hours since noon yesterday.

Pertinent Hx:

None

Last in/out:

Patient ate breakfast yesterday and a small meal last night.  He has not had breakfast today.  Patient states he has been trying to stay hydrated and drank 3 liters yesterday.  He urinated clear urine this morning.  Patient has not had a bowel movement today.

Events:

This illness began suddenly 24 hours ago. 

The patient reported that two daytick embedded.JPGs ago he found a tick imbedded in his left armpit.  He didn’t think it had been there long because he was diligent about checking for ticks.  

 

 

  

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

 



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