NHS SBAR
Prepared by: Dr. [Your Name]
I. Situation
Patient Name: Jane Doe
Patient ID: 675839
Date: 27th August 2050
Location: [Your Company Address], Ward 3B
Jane Doe has been admitted with severe abdominal pain and persistent nausea, which started approximately 12 hours ago. The pain is localized in the lower right quadrant and has progressively worsened. The patient also reports a mild fever of 100.4°F (38°C) and has been unable to keep any food or fluids down.
II. Background
Jane Doe is a 32-year-old female with a history of recurrent gastrointestinal issues. She has previously been diagnosed with irritable bowel syndrome (IBS), but this episode appears to be more severe and unresponsive to her usual management strategies. No recent changes in medication or diet have been noted. Her last health check-up was six months ago, with no significant findings.
III. Assessment
Upon physical examination, the patient exhibits signs of rebound tenderness in the lower right abdomen and slight guarding. Vital signs are as follows:
Vital Sign | Measurement |
|---|
Heart Rate | 98 bpm |
Blood Pressure | 118/76 mmHg |
Temperature | 100.4°F (38°C) |
Respiratory Rate | 16 breaths/min |
Laboratory tests have been ordered, including a complete blood count (CBC) and abdominal ultrasound. Preliminary results suggest an elevated white blood cell count, indicating possible infection or inflammation.
IV. Recommendation
It is recommended to consider the following steps:
Immediate Intervention: Initiate intravenous fluids and administer a broad-spectrum antibiotic until specific culture results are available.
Consultation: Refer to a gastroenterologist for further evaluation and possible surgical consultation if the diagnosis points towards appendicitis or another acute abdominal condition.
Monitoring: Continue close monitoring of vital signs and patient symptoms. Arrange for follow-up imaging as needed.
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