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Case Study 20 July 2011
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Case Study 20 July 2011
Page 2

The Setting

You’re the leader of a backpacking group that has been in the Bob Marshall Wilderness for the past 12 days.  Two days ago, you picked up a new ration from a horse packer.  You’re only three miles from the traBob Marshall Wilderness Sign.jpgil head, looking forward to moving farther into the wilderness.  One of your participants was not feeling well yesterday afternoon, so you sent them to bed early with advice to stay hydrated and rest. This morning you go check on how he is feeling.  

 

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 his tent.  He denies recent injury.  Patient exam is unremarkable: no rashes, insect bites, or wounds.

 

Vital Signs

TIME

0800hrs

LOR

A+Ox4

HR

72, strong, regular

RR

14, regular, easy

SCTM

pale, warm, dry

BP

radial pulses present

Pupils

PERRL

100.1°F (37.8°C) oral

 

History

 

Symptoms:

Dull headache, nausea, muscle aches, loss of energy and appetite. These symptoms began yesterday and have persisted through the night.  No other group members are 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 200 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.  His urine was clear this morning.  Patient has not had a bowel movement today. No diarrhea or vomiting.

Events:

Patient has been backpacking for 10 days.  This illness began suddenly 24 hours ago.

 

 

 

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



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