Patient SBAR
Prepared by: [Your Name]
Date: August 27, 2050
I. Situation
Patient Name: Michael Watson
Age: 65
Gender: Male
Date of Admission: July 28, 2050
Presenting Problem: Mr. Watson was admitted to [Your Company Name] with acute shortness of breath and chest pain radiating to his left arm. He has a history of hypertension and diabetes, currently presenting signs of potential acute myocardial infarction (AMI).
II. Background
Medical History | Medications | Allergies |
|---|
Hypertension (10 years) | Amlodipine, Metformin | Penicillin |
Type 2 Diabetes (8 years) | Insulin, Atorvastatin | None known |
Hyperlipidemia (5 years) | Lisinopril, Aspirin | None known |
Mr. Watson has a family history of cardiovascular diseases, with both parents having suffered heart attacks in their 60s. He is a former smoker, having quit 10 years ago, and drinks alcohol occasionally. He had an AMI five years ago and underwent stenting at [Your Company Name].
III. Assessment
Upon assessment, Mr. Watson exhibits:
Elevated blood pressure: 160/95 mmHg
Oxygen saturation: 89% on room air
EKG showing ST elevation in the anterior leads
Troponin levels elevated at 0.32 ng/mL
The patient is currently stable but requires immediate intervention due to the high risk of an evolving myocardial infarction.
IV. Recommendation
Immediate cardiology consultation.
Start on oxygen therapy with a goal of maintaining O2 saturation >94%.
Administer nitroglycerin and monitor for response.
Prepare for possible transfer to the cath lab if symptoms persist.
Continuous cardiac monitoring.
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