The Setting
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/Story/Summary
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 (highs in the low 90s F) 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 three 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.
| Vital Signs | TIME | 1530 hrs – supine | 1540 hrs –supine | 1600 hrs – standing |
| LOR | A+Ox4 | A+Ox4 | A+Ox4 | |
| HR | 130, regular, weak | 100, regular, weak | 76, regular, strong | |
| RR | 24, regular, shallow. Initial gasping for air has resolved and breathing is now quiet and easy. | 18, regular, shallow | 14,regular, easy | |
| SCTM | pale, cool, clammy | pale, warm, clammy | pink, warm, dry | |
| BP | radial pulses present | radial pulses present | radial pulses present | |
| Pupils | PERRL | PERRL | PERRL | |
| T° | Not taken | Not taken | Not taken |
Stop...
What is your Assessment and Plan?
Take a few minutes to figure out your own assessment and make a plan.
Don’t cheat—no reading on without answering this first!
Written By
Test Author 1
Lorem ipsum dolor sit amet, his deleniti concludaturque ei, aperiri salutandi adversarium sed ea. Est no audire abhorreant, his ex nibh omnes, mel nibh scribentur cu. Ex populo legimus consectetuer mea. Posse interesset cu cum, choro accusam ne vel, te eos tollit consetetur. Wisi voluptua detraxit sed ad.
Ei mel essent labitur dignissim, eum ut adhuc voluptaria. Putent corrumpit ne vel, ius ut appetere euripidis. At causae repudiare dignissim sea, pri alii regione eripuit no. At pri quod meliore facilisis. Cu prompta inimicus forensibus pri, at vis fugit assum, te noluisse persequeris per. Et vix rebum accumsan quaerendum. Dolorem comprehensam his ne, nam nobis nullam explicari ea.
