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:
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:
Increase Diuretic Dose: Consider increasing Lasix to 80 mg daily.
Consult Cardiology: Request an urgent cardiology consult for potential adjustments to heart failure management.
Oxygen Therapy: Administer supplemental oxygen to maintain saturation above 94%.
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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