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Case Study 26 Jan 2013
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Case Study 26 Jan 2013
Page 2

The Setting

You're day hiking with two friends, Nate and Mark, on a little used trail in steep timber.  It's a cool June day with lingering snow in the shaded north-facing slope.  The plan is to cover 8-10 miles, challenging your fitness and reconnoitering a possible future trip with spouses and children.  The day has gone well when you hear Nate, hiking ahead of you, say something we can't repeat in polite company.  You look up and see him slip on a patch of snow, slide down slope, hit a rock, flip over and slam pack first into a thick old pine tree.  It's an impressive tumble.

bandana.jpgYou and Mark look around and quickly decide you can avoid the snow and descend to Nate without kicking rocks onto him.  Nate has rolled away from the tree onto a flat pine needle covered bench.  You and Mark arrive at his side, drop your packs and wait for the other to do something.  This void needs a leader.  You step in, trying to recollect what you learned in last year's Wilderness First Aid course.  Mark kneels at Nate's side and tells him to stop moving. You remember the souvenir patient assessment bandanna wrapped around your head.  Taking a look at this helps you to focus and enter the Patient Assessment System. 

SOAP Report

Subjective/Story/Summary

The patient is a 42 year old male who tumbled about 20 yards down a steep slope, flipped once and struck a tree pack first.  He says his left hip and elbow and right shoulder hurt, but he thinks he's ok.  

Objective/Observations

Patient Exam: The patient rolled over once after he landed.  We found him on his right side with no bleeding.  We removed his pack and kept his head and back stable.  Initially he would not answer our questions although his eyes were open.  He does not think he lost consciousness, but he seemed stunned when we arrived at his side.  Currently he is awake and his level of consciousness seems normal.

The head-to-toe revealed pain to his left hip and elbow and right shoulder but there was no obvious injury and he can move those limbs.  The pain is a 4-5 on the 1-10 scale.  There is no pain in his back and he can move his legs and arms, denies any tingling or odd sensations and can feel when fingers and toes are touched.

Vital Signs
TIME

1300 hrs

LOR

awake and oriented

HR

90, regular

RR

20 not labored

SCTM

pale, warm, dry

History

Symptoms:

none

Allergies:

lots of hay fever allergies, not a problem at this time

Medications:

Claritin for his allergies, Ibuprofen as needed but not today, something for cholesterol taken daily

Pertinent Hx:

none

Last in/out:

2 liters on the trail today, not thirsty, urinated 30 minutes ago

Events:

we have been hiking for 4 hours, Nate was not dizzy, he just slipped

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




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