SBAR for Healthcare Students
Date: September 26, 2050
I. Situation
The patient, Jasen Gaylord, a 45-year-old male, was admitted to [Your Company Name] with a diagnosis of acute myocardial infarction (heart attack). He is currently stable but requires ongoing monitoring and treatment.
II. Background
Mr. Gaylord has a history of hypertension and hyperlipidemia. He experienced chest pain radiating to his left arm for the past hour before presenting to the emergency department. His vital signs upon admission were as follows:
Vital Sign | Value |
|---|
Blood Pressure | 160/100 mmHg |
Heart Rate | 98 bpm |
Respiratory Rate | 20 breaths/min |
Oxygen Saturation | 95% on room air |
He was started on aspirin and nitroglycerin and underwent a cardiac catheterization, which revealed 70% blockage in the left anterior descending artery.
III. Assessment
Currently, Mr. Gaylord is stable and reports mild chest discomfort, which is relieved with medication. He is alert and oriented, with no signs of respiratory distress. Heart sounds are normal, and there are no additional murmurs or gallops.
IV. Recommendation
It is recommended that the healthcare team continue to monitor Mr. Gaylord’s cardiac status closely, especially for any changes in chest pain or vital signs. Further treatment with a beta-blocker and statin should be initiated as per protocol. Additionally, a dietitian consult is recommended to discuss lifestyle modifications and dietary changes.
Please feel free to reach out to me for any further information or clarification regarding Mr. Gaylord’s care. I can be contacted at [Your Email] or you can reach me through [Your Company Email]. My name is [Your Name], and I am currently at [Your Company Name], located at [Your Company Address]. If you have any questions, you can also call me at [Your Company Number].
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