Med Surg SBAR

Med Surg SBAR

Prepared by:
Dr. [Your Name], MD

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.

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)

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.

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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