Question

.C. is a 41-year-old man who comes to the emergency department with complaints of acute low back
pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke
this morning with terrible back pain, which he rates as a 10 on a 1-to-10 scale. He admits to having had
a similar episode of back pain years ago "after I lifted something heavy at work." J.C. has a past medical
history of peptic ulcer disease (PUD) related to nonsteroidal anti-inflammatory drug (NSAID) use. He is 6
feet tall, weighs 265 pounds, and has a prominent "potbelly."

Please help me write an SBAR for this case

Answer 1

C is 41 year old male. He is having chief complaints of acute low back pain due to heavy lifting.

He had similar past history and also has past history of peptic ulcers related to NSAIDs.

SBAR stands for Situation, Background, Assessment and Recommendation. It is an easy to remember, mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action.” It gives clinicians a specific, unambiguous way to communicate critical information to one another, leaving little room for error and minimizing the chance that a miscommunication will cause patient deterioration.

SBAR FOR THIS CASE -

• Situation -

• Background -

• Assessment -

• Recommendations -

* Situation - Mr C is having acute low back pain that is due to heavy weight lifting and pain is getting worst from day of weight lifting to nxt morning.

* Background - The supporting background information is Mr C had similar past episode of back pain because of heavy lifting. He also had medical history of peptic ulcers.

• Assessment - My assessment for this case is that Mr C may be having a muscle or ligament strain , buldging disc or slipped disc or may be due to sciatica.

Recommendations - I recommend that mr C has to investigate for lower back pain. Investigation for muscle strain and/ or slipped disc.

and muscle strain and slipped disc are main reasons for lower back pain because of heavy weight lifting.

Patient should be given muscle relaxants and pain killers other than NSAIDs because he had a history of peptic ulcers. Muscle relaxants like baclofen or metaxalone and  pain killers other than NSAIDs may include acetaminophen like Tylenol. And further follow up is required for the patient.