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WMI Case Study: Fall from a Horse – Possible Spine and Head Injury – When to use a Wilderness Protocol
The Setting: You and your WFR trained co-instructor are leading a group of high school students into the mountains for a week long spring break backpacking trip. A half-mile from the road head you see a lone horse and rider come down the main trail. Suddenly the horse begins to rear and buck and you watch as the rider falls off the back of the horse and lands on his head and shoulder. The weather is warm and sunny.
Name: John Doe
Date: April 24, 2004
SOAP Report
Subjective:
The patient is a 45 yr old male who fell from his horse landing on his head and left shoulder. Patient slid off the back of the horse while the horse was rearing. He did not appear to be trampled by the horse. The patient’s chief complaint is a dull headache he rates as a 4 on a scale of 1-10. The headache began shortly after his fall.
Objective:
The patient was found lying on his back on the trail. Initially the patient was not awake, but was responsive (he moaned) to a verbal stimulus. Shortly thereafter he began to wake-up and within one to two minutes he became A+OX4.
Patient Exam:
Patient has a golf ball sized bruise/swelling on his left temple and a 3” bruise/abrasion on his left shoulder. The patient is moving his arms and legs, denies pain on palpation of the spine and has good circulation, sensation and motion (CSM) in all 4 extremities. No other injuries found.
Vital Signs:
| TIME |
10:15AM |
10:45AM |
| LOC |
Responsive to verbal stimulus |
A+Ox4 |
| HR |
84, strong, regular |
72, strong, regular |
| RR |
12, regular, easy |
12, regular, easy |
| SCTM |
Pale, Warm, Dry |
Pink, Warm, Dry |
| Pupils |
PERRL |
PERRL |
| Temp |
not taken |
not taken |
History:
Symptoms: Patient states he has a headache and is slightly nauseous.
Allergies: Patient is allergic to peanuts with no recent exposure.
Medications: Patient takes a medication for high blood pressure. He took his normal dose today.
Pertinent Medical History: High Blood Pressure. Peanut Allergy.
Last intake/output: Patient reports he drank a liter of water this morning, ate breakfast and had a normal bowel movement. He vomited once shortly after the accident.
Events relevant to the incident/illness: None
What is your Assessment and Plan?
*DO NOT click without answering first.
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