The Setting
You and your climbing partner are midway through what has been an exceptional climbing vacation in the desert. You are car camping in the surrounding National Forest. Highway 125 is 30 minutes away via dirt road, the nearest town one additional hour away.
Well into the morning, the two of you have attained a spacious ledge from which you “rope up” to start the first pitch of a multi pitch route. Your partner has the lead and he is approximately 30 feet off the deck and six feet above his last piece of protection. At this point you notice him starting to struggle with a section of the climb. He hesitates and starts the move repeatedly. Knowing this to be a harbinger of bad things to come, you brace yourself for a fall. Immediately afterwards he comes off the route and swings into the rock about 12 feet below his high point. His feet impacted first and he grabs his right ankle, signaling a possible end to the road trip.
SOAP Report
Subjective/Story/Summary
The patient is a 27-year-old male whose chief complaint is pain in the right ankle. Patient fell approximately 12 feet while rock climbing, absorbing the force of the fall with right side of body and feet. Patient was wearing a helmet. He did not hit his head. Patient is currently A&O x 4.
Objective
Patient Exam:
Patient was lowered to a ledge without incident, and is resting comfortably on his back. Head-to-toe revealed a two-inch long, quarter inch-wide laceration to right lateral mid thigh and abrasions along the right lower leg. The right ankle is swollen with pain and general tenderness, but no point tenderness and good CSM in the toes. No other injuries were found. Patient denies head, neck, and back pain. There was no loss of responsiveness.
Vital Signs
| TIME | 10:15 AM | 11:00 AM |
| LOR | A&Ox4 | A&Ox4 |
| HR | 88, strong, regular | 64, strong, regular |
| RR | 24, shallow, regular | 12, deep, regular |
| SCTM | Pink Warm Dry | Pink Warm Dry |
| BP | PERRL | PERRL |
| Pupils | Strong radial pulse | Strong radial pulse |
| Temp | Not taken | Not taken |
History
| Symptoms: | The patient complains of nausea |
| Allergies: | peanuts/ one severe reaction several years ago/ no recent exposure |
| Medications: | 400 mg Ibuprofen, this morning, for minor aches |
| Pertinent Hx: | denies pertinent history |
| Last in/out: | Breakfast this morning, 1 L H2O. outputs are unremarkable |
| Events: | no pertinent events |
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