The Setting
You’re the supervisor for several crews doing volunteer trail maintenance in a local national forest. Your crew leaders are new, so you want to keep a close watch on the crews. Plus, it’s a good reason to get out of the office, away from the email, and enjoy a hike in the hills.
The weather has been unusually hot and humid, with daytime temperatures in the 90s °F ( (30s °C). You find one of your crews around lunch, resting under a few trees. They look lethargic and tired. The crew boss has one of the crewmembers lying on his back with feet elevated and a wet bandanna on his forehead. You ask if you can help and your crew leaders gives you a SOAP report on the patient.
SOAP Report
Subjective/Story/Summary
The patient is an 19-year-old male who complains of weakness, dizziness, heat stress, and a headache.
Objective
Patient Exam
The patient is supine with feet elevated. He denies falling or any injuries and head-to-toe exam does not find any sign of injury.
Vital Signs
| TIME | 1215 hrs |
| LOC | A+Ox4 |
| HR | 80, strong, regular |
| RR | 20, shallow, unlabored, regular |
| SCTM | warm, pale, sweaty |
| BP | Radial pulses present |
| Pupils | PERRL |
| Temp | 99°F oral |
History
| Symptoms: | Patient states he feels weak, dizzy and has a headache. |
| Allergies: | Patient denies allergies. |
| Medications: | Patient has been taking 200-400 mg ibuprofen daily for minor muscle aches. |
| Pertinent Hx: | Patient denies any pertinent medical history. |
| Last in/out: | Patient ate breakfast and states he drank 1.5 liters of water today with some Gatorade mixed in. |
| Events: | Patient has been working on a trail crew for several days. |
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!
