You’re the leader of a backpacking group that has been in the Bob Marshall Wilderness for the past 12 days. Two days ago, you picked up a new ration from a horse packer. You’re only three miles from the trailhead, looking forward to moving farther into the wilderness. One of your participants was not feeling well yesterday afternoon, so you sent them to bed early with advice to stay hydrated and rest. This morning you go check on how he is feeling.
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 his tent. He denies recent injury. Patient exam is unremarkable: no rashes, insect bites, or wounds.
Vital Signs
TIME |
0800hrs |
|
LOR |
A+Ox4 |
|
HR |
72, strong, regular |
|
RR |
14, regular, easy |
|
SCTM |
pale, warm, dry |
|
BP |
radial pulses present |
|
Pupils |
PERRL |
|
T° |
100.1°F (37.8°C) oral |
History
|
Symptoms: |
Dull headache, nausea, muscle aches, loss of energy and appetite. These symptoms began yesterday and have persisted through the night. No other group members are 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 200 mg every 4 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 3 liters yesterday. His urine was clear this morning. Patient has not had a bowel movement today. No diarrhea or vomiting. |
|
Events: |
Patient has been backpacking for 10 days. This illness began suddenly 24 hours ago. |
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