Question

Need SBAR

Dx: Ectopic Pregnancy (patient admitted for abdominal pain)

History: The patient presents with abdominal pain that radiates to her shoulders and back.

                The patient woke up this morning with pain and menstrual cramping and now bleeding.

first vital sign: BP: 130/89, HR:125, RR:16 O2: 97%

second vital sign: BP: 50/20, HR:0, RR:4 O2: 0% (cardiac arrest)

Symptoms: Abdominal pain, bleeding, shoulder pain

does:  performing CPR, O2 maximum, IV: maximum,

Answer 1

ANSWER :

SBAR : Ectopic pregnancy.

SITUATION(S):

Female patient name _______,age _____ ,months of amenorrhea __________ came with presenting complaint of abdominal pain since today morning(date and time to be mentioned) and admitted for further management.

Diagnosis : Ectopic pregnancy

BACKGROUND(B):

History of presenting complaint :

• Her presenting complaint started early morning , when she woke up with pain and menstrual cramping.
• History of pain started in the lower abdomen radiating to her shoulders and back.
• Pain associated with bleeding now.

ASSESSMENT(A):

General examination :

• General condition of patient to be assessed
• Vital status - first : BP : 130/89, HR : 125 , RR : 16 ,O2 : 97% ; second : BP:50 /20, HR :0 ,RR : 4 ,O2 : 0% (cradiac arrest).

Local examination :

• Per abdomen examination :look for abdomen distension and do paracentesis(for haemoperitoneum).
• Per vaginal examination(done gently) : look for uterus size , fornicial fullness and tenderness and watch for any bleeding.

Treatment given : Performing CPR,O2 maximum and IV maximum.

RECOMMENDATIONS(R):

• CPR should be continued and patient should be kept on mechanical ventilator.
• Once patient revived after CPR , start inotropic support.
• Give IV antibiotics.
• Advise for blood and blood products tranfusion
• Plan for emergency laparotomy under general anaethesia.