SBAR Critical Care Report
SBAR Critical Care Report
Prepared by: [Your Name], RN
Date: September 26, 2050
I. Situation
Patient Name: Agustin Jerde
Patient ID: 123456
Age: 62 years
Gender: Male
Admitting Diagnosis: Acute Myocardial Infarction
Current Condition: The patient is stable but remains under close observation. He is experiencing persistent chest pain rated at 6/10, which is not alleviated by nitroglycerin.
II. Background
Medical History:
-
Hypertension: Diagnosed 10 years ago, managed with lisinopril.
-
Diabetes Mellitus: Type 2, diagnosed 5 years ago, controlled with metformin.
-
Previous Myocardial Infarction: 3 years ago: treated with angioplasty and stenting.
Medications:
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Lisinopril 20 mg daily
-
Metformin 1000 mg twice daily
-
Aspirin 81 mg daily
-
Atorvastatin 40 mg daily
Allergies:
-
No known drug allergies (NKDA)
III. Assessment
Vital Signs:
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Blood Pressure: 130/85 mmHg
-
Heart Rate: 98 beats per minute
-
Respiratory Rate: 18 breaths per minute
-
Temperature: 98.6°F (37°C)
-
Oxygen Saturation: 95% on room air
Physical Examination:
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General Appearance: Alert but in mild distress due to chest pain.
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Cardiovascular: Regular rhythm, no murmurs; persistent chest pain upon palpation.
-
Respiratory: Clear to auscultation bilaterally; no wheezes or crackles.
IV. Recommendation
The patient requires further evaluation by a cardiologist to assess the current state of coronary arteries and determine if additional intervention is necessary. A repeat ECG and cardiac enzyme tests are recommended to rule out any further complications.
Consulting Specialist: Dr. Emmy Green
Contact Information: [Your Name], [Your Email], [Your Company Name], [Your Company Email]
Table of Recent Interventions
|
Date |
Intervention |
Result/Observation |
|---|---|---|
|
09/25/2050 |
Administered nitroglycerin SL 0.4 mg |
Pain reduction temporarily to 4/10 |
|
09/25/2050 |
Cardiac monitor initiated |
Continuous telemetry, no arrhythmias |
|
09/26/2050 |
Repeat ECG performed |
ST-segment changes noted |
Please contact me at [Your Company Number] if you need further information or clarification regarding this patient's condition. Thank you for your attention to this matter.
