Patient Handoff SBAR

Date: September 26, 2050

I. Situation

Patient Name: Dell Stokes
MRN: 123456
Age: 72 years
Room Number: 405
Diagnosis: Acute Myocardial Infarction

Dell Stokes is a 72-year-old male admitted with an acute myocardial infarction. He underwent a successful percutaneous coronary intervention (PCI) two days ago. He is currently stable but requires monitoring for any complications.

II. Background

Dell has a history of hypertension and hyperlipidemia. He is currently on the following medications:

Medication	Dose	Frequency
Aspirin	81 mg	Daily
Metoprolol	50 mg	Twice Daily
Atorvastatin	20 mg	Daily
Nitroglycerin	0.4 mg SL as needed	Every 5 minutes (max 3 doses)

During his hospitalization, he experienced mild chest pain, which was relieved with nitroglycerin. He has been compliant with medications and dietary restrictions.

III. Assessment

Vital Signs:

• Blood Pressure: 130/85 mmHg

• Heart Rate: 75 bpm

• Respiratory Rate: 18 breaths/min

• Oxygen Saturation: 97% on room air

Physical Assessment:

• Cardiac: Regular rhythm, no murmurs

• Respiratory: Clear to auscultation bilaterally

• Abdomen: Soft, non-tender

• Extremities: Warm, pulses intact

Current Concerns:

• Monitor for signs of bleeding, especially due to recent PCI.

• Encourage mobility to prevent complications from immobility.

IV. Recommendations

1. Continue the current medication regimen as prescribed.

2. Assess vital signs every 4 hours, with additional monitoring if changes occur.

3. Encourage Dell to ambulate at least twice a day to enhance recovery.

4. Notify the on-call physician if chest pain recurs or vital signs fluctuate significantly.

Contact Information:

Handover to: [Your Name]
Email: [Your Email]
Company Name: [Your Company Name]
Company Number: [Your Company Number]

Please ensure that the next shift is updated on any changes in Dell’s condition and that his dietary needs are met.

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