Med Surg SBAR

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Prepared by:
Dr. [Your Name], MD

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I. Situation

Patient Name: Sarah Thompson
Age: 72
Gender: Female
Date: August 27, 2050
Location: Room 305, [Your Company Address]

Summary:

Sarah Thompson, a 72-year-old female, has been admitted for worsening chronic heart failure. Her condition has deteriorated over the past 24 hours, with increased shortness of breath and edema in the lower extremities.

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II. Background

Medical History:

• Chronic Heart Failure

• Hypertension

• Type 2 Diabetes Mellitus

Current Medications:

• Lasix 40 mg daily

• Lisinopril 20 mg daily

• Metformin 500 mg twice daily

Recent Changes:

• Increased weight by 4 lbs over the last 3 days

• Elevated blood pressure (160/95 mmHg)

• Decreased oxygen saturation (90% on room air)

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III. Assessment

Vital Signs:

Parameter	Value
Heart Rate	88 bpm
Respiratory Rate	22 breaths/min
Blood Pressure	160/95 mmHg
Oxygen Saturation	90%
Temperature	98.6°F

Physical Examination Findings:

• Bilateral pitting edema in the lower extremities

• Elevated jugular venous pressure

• Diminished breath sounds bilaterally

Clinical Impression:

Sarah’s worsening symptoms suggest an exacerbation of her chronic heart failure. The elevated blood pressure and reduced oxygen saturation are concerning and require immediate intervention.

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IV. Recommendation

Proposed Interventions:

1. Increase Diuretic Dose: Consider increasing Lasix to 80 mg daily.

2. Consult Cardiology: Request an urgent cardiology consult for potential adjustments to heart failure management.

3. Oxygen Therapy: Administer supplemental oxygen to maintain saturation above 94%.

4. Monitor Vital Signs: Increase monitoring frequency to every 2 hours.

Contact Information:

• [Your Company Name]

• [Your Company Number]

• [Your Company Email]

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