The Setting
You’re setting up camp at an established campground a few miles from town after a long day on your road bikes. Your companion was climbing a tree to set a line to keep food from bears. A branch snaps and he falls hard from about 15’ up, landing on his upper back. Before you think about it you find yourself kneeling at his head, controlling the cervical spine with your hands – a result of your Wilderness First Responder (WFR) course. You calm yourself, focus, and begin the patient assessment.
SOAP Report
Subjective/Story/Summary
The patient is a 30-year-old male who fell about 15’ out of a tree when a branch broke. He landed on his upper back. He did not lose responsiveness. He is complaining of right shoulder and upper back pain.
Objective
Patient Exam:
The patient was found on his back. He has no visible injuries. He is complaining of pain in his upper back on the spine and in the surrounding muscles. There is some tenderness around the spine right between the shoulder blades. CSM are good in all extremities.
Vital Signs
| TIME | 5:30PM |
| LOR | A+Ox4 |
| HR | 76, strong, regular |
| RR | 18, regular, easy |
| SCTM | pink, warm, dry |
| B.P. | radial pulse present |
| Pupils | equal and reactive |
| T° | not taken, states he is warm |
History
| Symptoms: | none |
| Allergies: | denies |
| Medications: | ibuprofen occasionally for muscle aches from exercise |
| Pertinent Hx: | none |
| Last in/out: | drank 4 liters of water today, urinated 2X with a normal BM |
| Events: | The fall from the tree was not caused by a fainting event. |
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!
