Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with symptoms consistent with Acute Mountain Sickness (AMS) following rapid ascent to [Insert Altitude] meters over [Insert Time] hours. Primary complaints include headache, nausea, fatigue, dizziness, and difficulty sleeping. Patient denies ataxia, altered mental status, or resting dyspnea. Lake Louise Score (LLS): [Insert Score].
Clinical Examination Findings
General: Patient appears [distressed/lethargic]. Vitals: HR [Insert], BP [Insert], SpO2 [Insert] on room air. HEENT: No conjunctival injection. Respiratory: Lungs clear to auscultation bilaterally, no rales or wheezing. Cardiovascular: Regular rate and rhythm, no murmurs. Neurological: Alert and oriented x3, no focal deficits, gait steady, no signs of ataxia.
Treatment Protocol
Plan: 1. Halt further ascent immediately. 2. Consider descent if symptoms worsen or fail to improve. 3. Hydration and rest. 4. Acetazolamide [Insert Dose] mg PO BID. 5. Analgesics for headache (e.g., Ibuprofen/Acetaminophen). 6. Supplemental oxygen if SpO2 < 85% or symptomatic. 7. Monitor for signs of HAPE/HACE.