You are leading a college spring break backpacking trip in a remote area of the Grand Canyon. One of your participants develops a rash on his belly that begins to spread.
SOAP Report
Subjective
The patient is a 19-year-old male who developed a skin rash that has spread over 30% of his body.
Objective
Patient Exam: At 1600 hrs March 6 the patient has a red raised bumpy rash that does not have blisters. He states it began this morning on his belly and has spread through the day to cover his lower back, abdomen, and the front of his thighs. The rash produces a constant itching. There is a vague sensation of chest tightness but no shortness of breath and no respiratory involvement.
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Vital Signs |
TIME |
1615 hrs |
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LOR |
A+Ox4 |
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HR |
72, strong, regular |
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RR |
16, regular, unlabored |
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SCTM |
pink, warm, dry |
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BP |
radiul pulses present |
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Pupils |
PERRL |
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Temp |
98.9°F (37.1°C) oral |
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History |
Symptoms: |
None stated other than the itching rash |
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Allergies: |
Seasonal hay fever. |
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Medications: |
Claritin for seasonal allergies. Not taking the medication at this time. |
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Pertinent Hx: |
Pt has never had a response like this. He had shortness of breath and throat swelling in response to a bee sting several years ago and was prescribed an Epipen®. He has not had a response since and does not know the location of his EpiPen® . |
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Last in/out: |
Patient is well-hydrated; normal clear urine and bowel movements today. |
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Events: |
Patient has been backpacking for the past three days. No new medications taken. He does not consider the backpacking ration a change in his food types. |