Case Study 35

The Scenario: Hot Day for a Hike

The Setting

Daytime temps of 40C/104F. Your group of four encounters a patient lying on the ground under the only small juniper in the area.  You ask if everything is OK. The patient’s companion is fine but he asks if you can help with the patient, who he worries is dehydrated or having a “heat stroke.” You perform a patient assessment then discuss your findings and the situation with your companions, the patient, and their companion.

SOAP Report

Subjective

The patient is a 30-year-old female complaining of fatigue, dizziness, and a headache. The patient is hiking with a companion in the desert. This is the second day. 

Objective

Patient Exam: The patient has no mechanism for injury and there are no findings on a head-to-toe physical exam except swollen fingers, which patient says she has never had before.

Vital Signs

TIME

1030hrs

LOR

According to companion the patient is slow to respond but is A+Ox4

HR

90, strong, regular

RR

20, regular, easy

SCTM

pale, warm, moist

B.P.

radial pulse present

Pupils

PERRL

38C (100F) oral

History

Symptoms:

Fatigue (unanticipated in a fit person), dizziness, dull throbbing headache.  Denies thirst.

Allergies:

None

Medications:

None

Pertinent Hx:

No relevant history

Last in/out:

Yesterday: drank 8 liters of water and urinated several times. Today drank 4 liters of water and urinated once in the morning prior to stopping.  Drank 1 additional liter in last hour. Urine was clear. Ate only one bagel at breakfast.

Events:

Hiking yesterday (8 miles) and today (5 miles) in 40C/104F temperatures and cloudless sky. The patient is wearing a broad-brimmed straw hat, shorts, and a loose, thin, white cotton shirt.

Stop ...

What is your Assessment and Plan?

DO NOT click/peek at the next page without answering this first.