Case Study 5

The Scenario: Succumbing to the Heat

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/Summary/Story
The patient is an 19-year-old male who complains of weakness, dizziness, heat stress, and a headache.

Objective/Observations/Findings
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 

1215hrs

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?

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