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:
Allergies:
III. Assessment
Vital Signs:
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:
General Appearance: Alert but in mild distress due to chest pain.
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.
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