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Case Study 15 May 2010
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Case Study 15 May 2010
Page 2

The Settingcanyon hiking2.jpg

You and three friends have been hiking 18-20 miles a day for three days in the desert southwest.  It’s been hard and hot as anticipated, but not scorching hot.  You’ve found water every day.  This afternoon you backpacked over a steep sun drenched sandstone ridge and down into a cottonwood glade.  One of your companions has been lagging behind and eventually stops and sits by the side of the trail.  He looks pasty white and sweaty and says he feels awful.  Your scene size up is brief; no hazards, one patient who looks sick and sat down.  You think about BSI but keep your limited glove supply in your first aid kit for now.  The patient agrees to your assessment, has a sound airway, is breathing without distress, is dressed in only shorts and t-shirt, is obviously not bleeding, has a strong radial pulse and is on dry ground in the shade on a nice warm day. 

 

SOAP Report

Subjective

The patient is a 24 year old male who states he “feels lousy.”  He has been backpacking long distances for three days in hot weather (high’s in the low 90’sF) and this afternoon became too weak to hike. 

 

Objective

Position found: Patient sat down by the side of the trail.  There is no mechanism for injury.

 

Patient Exam:  No obvious injuries were found in a head-to-toe assessment.  Patient is pale and sweating.  Skin is not hot to the touch and the patient has a normal mental status.

 

 

Vital Signs

 TIME          1300

 LOR           A+Ox4

 HR            100, strong, regular

 RR            18, easy and regular

 SCTM       pale, warm and moist

 BP            strong radial and pedal pulse

 Pupils      PERRL

 T°             not taken

 

History           

Symptoms: Patient states he is dizzy, nauseous and “feels lousy”

Allergies: None stated

Medications: Occasional ibuprofen at 400-600mg for muscle soreness, none today

Pertinent Hx: Patient denies any ongoing medical conditions.

Last in/out: Patient drank 3 liters of fluid so far today, ate breakfast and ongoing trail snacks, urinated a light yellow urine twice today and stated this is normal on long hikes.  He had a normal BM this morning.  Denies recent diarrhea or vomiting.

Events: Patient has been hiking in hot dry weather for three days, 18-20 miles per day without problems.   He has not fallen or suffered any injuries.

 

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

 



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