Free Medical SBAR

Prepared by: Nurse [Your Name]

I. Situation

Date: August 27, 2050
Time: 08:15 AM
Patient Name: John Doe
Patient ID: 123456789
Location: Room 304, [Your Company Name]

Summary of Situation:
Mr. John Doe, a 65-year-old male admitted with a diagnosis of congestive heart failure, has experienced a sudden and significant change in his condition. At 07:45 AM, the patient developed acute shortness of breath and a persistent cough.

II. Background

Relevant Medical History:

• Primary Diagnosis: Congestive Heart Failure

• Comorbidities: Hypertension, Type 2 Diabetes

• Recent Procedures: None in the past 24 hours

Current Medications:

Recent Vital Signs:

III. Assessment

Clinical Assessment:

• Physical Examination: The patient presents with bilateral crackles on lung auscultation and an increased respiratory rate. The patient appears dyspneic and is using accessory muscles to breathe.

• Changes in Condition: Notable decrease in oxygen saturation levels (SpO2 88% on room air), which has not improved with supplemental oxygen (2 L/min via nasal cannula).

• Current Concerns: Possible exacerbation of heart failure or an underlying respiratory infection. Immediate intervention is required.

IV. Recommendation

Suggested Actions:

1. Immediate Evaluation: Request urgent evaluation by a cardiologist to assess the need for advanced cardiac intervention.

2. Diagnostic Tests: Order chest X-ray and arterial blood gases (ABG) to determine the extent of pulmonary and cardiac involvement.

3. Treatment Adjustments: Consider adjusting diuretics and initiating broad-spectrum antibiotics if a respiratory infection is suspected.

4. Monitoring: Continuous monitoring of vital signs and oxygen saturation levels. Consider placing the patient on a higher-flow oxygen device if necessary.

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