You’re working out of a remote ranch on the sagebrush plains of southern Idaho. It’s early May and several of you ride and walk daily to survey herds of pronghorn as part of a research program and a master's thesis. One of your classmates goes to bed feeling lousy and wakes up feeling worse. Knowing you have training as a Wilderness First Responder (WFR), you’re asked to take a look at this poor fellow.
SOAP Report
Subjective
The patient is a 21-year-old male complaining of a headache, nausea, muscle aches, fever, and chills. These symptoms began yesterday and have persisted through the night.
Objective
Patient Exam
The patient is in his sleeping bag in the bunkhouse. He denies recent injury.
Vital Signs
TIME |
6:30 a.m. |
|
LOR |
A+Ox4 |
HR |
72, strong, regular |
|
RR |
14, regular, easy |
|
SCTM |
Pale, warm, dry |
|
BP |
Radial pulses present |
|
Pupils |
PERRL |
|
T° |
101°F (38.3°C) |
History
|
Symptoms: |
Dull headache, nausea, muscle aches, loss of energy and appetite. No diarrhea, vomiting, sore throat, neck stiffness, shortness of breath, cough, or sinus congestion. These symptoms began yesterday and have persisted through the night. No known cause. Other group members are not experiencing these symptoms. |
|
Allergies: |
Patient thinks he may be allergic to “cillin” antibiotics but does not remember a specific event causing this concern. |
|
Medications: |
Patient is not on any regular medications. For this illness he has been taking ibuprofen 400 mg every four hours since noon yesterday. |
|
Pertinent Hx: |
None |
|
Last in/out: |
Patient ate breakfast yesterday and a small meal last night. He has not had breakfast today. Patient states he has been trying to stay hydrated and drank three liters yesterday. He urinated clear urine this morning. Patient has not had a bowel movement today. |
|
Events: |
This illness began suddenly 24 hours ago. The patient reported that two day |
s ago he found a tick imbedded in his left armpit. He didn’t think it had been there long because he was diligent about checking for ticks.