SBAR Framework

Date: September 26, 2050

I. Situation

The patient, Jean Harris, is a 65-year-old male admitted with acute respiratory distress secondary to pneumonia. He is currently on supplemental oxygen and requires continuous monitoring due to fluctuating oxygen saturation levels.

II. Background

Jean Harris has a medical history significant for chronic obstructive pulmonary disease (COPD) and hypertension. He has been treated with bronchodilators and corticosteroids. A chest X-ray revealed bilateral infiltrates, confirming the diagnosis of pneumonia. His current medications include:

Medication	Dosage	Route
Albuterol	2.5 mg	Inhalation
Prednisone	20 mg	Oral
Amoxicillin	500 mg	Oral

III. Assessment

Upon examination, Jean Harris appears to be in moderate respiratory distress. Vital signs are as follows:

Vital Sign	Value
Blood Pressure	130/85 mmHg
Heart Rate	110 bpm
Respiratory Rate	24 breaths/min
Oxygen Saturation	88% on 4L O2

Auscultation of the lungs reveals diminished breath sounds bilaterally with wheezing. The patient's condition is stable but requires ongoing assessment and intervention.

IV. Recommendation

It is recommended to:

1. Increase supplemental oxygen to 6L via nasal cannula to maintain oxygen saturation above 92%.

2. Administer a nebulized bronchodilator every four hours.

3. Reassess respiratory status every hour and consider an early consult with a pulmonologist if no improvement is noted.

For further inquiries or updates regarding Jean Harris's status, please contact Nurse [Your Name] at [Your Email] or call [Your Company Number].

Thank you for your attention to this matter.

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