Simple Pediatrics SBAR

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Prepared by: [Your Name]

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I. Situation

Patient Name: Sophie Fadel
Age: 4 years old
Gender: Female
Date of Birth: March 21, 2046
Date: August 27, 2050
Time: 14:30
Location: [Your Company Name], Pediatrics Department

Situation Summary:

Sophie was brought to the ER by her mother, Mrs. Jacklyn Fadel, due to a persistent high fever (39.5°C/103.1°F) for the last 48 hours, coupled with decreased appetite, lethargy, and occasional vomiting. Her condition has worsened over the past few hours, prompting her mother to seek urgent medical attention.

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II. Background

Parameter	Details
Past Medical History	Sophie is a generally healthy child with no prior hospitalizations or significant medical issues. She has had routine vaccinations as per schedule.
Family History	No significant family history of genetic disorders or major illnesses. Both parents are healthy.
Medications	Currently not on any medication.
Allergies	No known drug or food allergies.
Social Background	Sophie lives with both parents in a single-family home. No recent travels or exposure to illness. She attends daycare.

Additional Information:

Sophie's fever was initially responsive to acetaminophen but has since become resistant. Her mother reports a recent outbreak of viral infections at her daycare center.

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III. Assessment

General Appearance:

• Lethargic, irritable, and moderately dehydrated.

Vital Signs:

• Temperature: 39.5°C (103.1°F)

• Heart Rate: 132 bpm (tachycardia)

• Respiratory Rate: 28 breaths per minute (elevated)

• Blood Pressure: 92/58 mmHg (normal for age)

• Oxygen Saturation: 98% on room air

Physical Examination:

• Head, Eyes, Ears, Nose, Throat (HEENT): No abnormalities noted.

• Cardiovascular: No murmurs, regular heart sounds.

• Respiratory: Clear to auscultation bilaterally.

• Abdominal: Mild tenderness, no organomegaly.

• Neurological: Alert but irritable, no focal deficits.

Preliminary Diagnosis:

Suspected viral illness (possibly gastroenteritis or a viral infection)

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IV. Recommendation

Immediate Actions:

1. Administer IV fluids to address dehydration.

2. Administer antipyretic medication (acetaminophen or ibuprofen).

3. Obtain blood work, including a complete blood count (CBC) and electrolyte panel.

4. Initiate urinalysis and stool cultures to rule out bacterial infection.

5. Monitor vitals every 30 minutes.

Future Considerations:

1. If fever persists beyond 48 hours with no clear source, consider imaging (chest X-ray, abdominal ultrasound) and possible hospitalization for observation.

2. Reassess after lab results to determine if further intervention, such as antibiotics, is necessary.

Family Education:

Discuss potential viral etiology with the mother and the importance of hydration and fever control. Advise on when to return to the ER (e.g., worsening symptoms, persistent vomiting, or inability to hydrate).

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