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Case Study 19 May 2011
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Case Study 19 May 2011
Page 2

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Five days into sea kayaking with friends in Prince William Sound, Alaska you feel lousy; some diarrhea, some vague abdominal cramping, not much appetite.  You assume it's a touch of the flu and don't say anything.  The next day you feel better and paddle all day.

 

That night you wake with the worse abdominal pain you have ever experienced.  You endure it quietly and it subsides after 30 minutes.  At breakfast you tell your companions about it.  The Wilderness First Responder (WFR) in the group begins a series of questions which he writes into a document he calls a SOAP report.  You don't think you're very ill, but he's your friend, so you allow him the chance to do his "patient assessment."

 

SOAP Report

Subjective

Patient is a 26 year old male whose chief complaint is "I don't feel great, but I've felt worse."   He appears pale, with normal mental status and can walk.  He states he has been feeling poor for the past 2 days with occasional diarrhea.  He has been able to paddle his sea kayak on several long days.  Last night he had 30 minutes of the "worst hard cramping pain he has ever experienced."  "I have a new 10 on a 1-10 scale."   He also reported his "belly was hard as a rock".  The episode subsided and the patient was able to sleep the remainder of the night. 

 

Objective

Patient Exam: Patient denies any recent injury and we have been together and have not witnessed any injury.  He refuses a head-to toe exam, but agrees to an abdominal exam.  He has some tenderness throughout his abdomen, no localized pain, but sharp pain in his lower right belly on a tap on his right foot.

 

Vital Signs
TIME

7/23 8:30 AM

7/23 9:30AM

LOR

A+Ox4

A+Ox4

HR

90 strong, regular

94 strong, regular

RR

15 regular, easy

15 regular, easy

SCTM

pale, warm, dry

pale, warm, dry

B.P.

strong radial pulse

strong radial pulse

Pupils

not taken

not taken

98.4°F (36.8°C) oral

not taken

 

 

 

History

Symptoms:

At present he has constant and dull generalized abdominal pain that is a 2 compared to last night's 10.  States he has general feeling of being "sick".

Allergies:

Denies

Medications:

Has been taking 400mg ibuprofen 4x a day for the past week for shoulder aches.

Pertinent Hx:

None.  Patient has his appendix.

Last in/out:

Has been well hydrated with clear yellow urine past several days,  Drank several cups of water this morning,  No BM.  He ate a light breakfast.

Events:

Feeling ill past several days.

 

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



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