SBAR for Syncope
Prepared by: [Your Name]
I. Situation
Patient: Jane Doe
Age: 65
Gender: Female
Date: August 27, 2050
Location: [Your Company Address]
Jane Doe, a 65-year-old female, presented with an episode of syncope that occurred earlier today. The patient was found on the floor by her family after losing consciousness for approximately 30 seconds. She regained consciousness spontaneously but reported feeling lightheaded and disoriented. There were no accompanying symptoms such as chest pain or palpitations prior to the event.
II. Background
Jane Doe has a history of hypertension and diabetes mellitus type 2. She is currently on medication for her hypertension and is otherwise compliant with her diabetes management. Her family history includes cardiovascular disease, with her father having experienced a myocardial infarction at age 70. The patient has no known history of syncope prior to this incident.
III. Assessment
Physical Examination Findings:
Vital Signs | Findings |
|---|
Blood Pressure | 130/85 mmHg |
Heart Rate | 72 bpm |
Respiratory Rate | 18 breaths/min |
Temperature | 98.6°F (37°C) |
Neurological Examination:
Alert and oriented to person, place, and time.
No focal neurological deficits observed.
No signs of trauma or injury.
Initial Diagnostic Tests:
ECG: Normal sinus rhythm, no acute changes.
CBC: Within normal limits.
Electrolytes: Mildly elevated potassium.
IV. Recommendation
Given Jane Doe’s episode of syncope, it is recommended that she undergoes further evaluation to determine the underlying cause. Suggested evaluations include:
Holter Monitor: To check for missed arrhythmias from the initial ECG.
Echocardiogram: To evaluate for structural heart disease.
Orthostatic Vital Signs: To check for postural hypotension as a cause of syncope.
It is also advised that Jane Doe be monitored for any recurring symptoms or changes in her condition. Follow-up with a cardiologist is recommended to address any cardiovascular concerns.
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