Question

J.G., a 49-year-old man, was seen in the emergency department 4 days ago, diagnosed with alcohol intoxication, and released after 8 hours to his brother's care. He was brought back to the ED 12 hours ago with an active gastrointestinal (GI) bleed and is being admitted to the intensive care unit (ICU); his diagnosis is upper GI bleed and alcohol intoxication.

You are assigned to admit and care for J.G. for the remainder of your shift. According to the ED notes, his admission vital signs (VS) were 84/56, 110, 26, and he was vomiting bright red blood. He was given IV fluids and transfused 6 units of packed red blood cells (PRBCs) in the ED. On initial assessment, you note that J.G:s VS are blood pressure 154/90, 110, 24; he has a slight tremor in his hands, and he appears anxious. He complains of a headache and appears flushed. You note that he has not had any emesis and has not had any frank red blood in his stool or melena (black tarry stools) over the past 5 hours. In response to your questions, J.G. denies that he has an alcohol problem but later admits to drinking approximately a fifth of vodka daily for the past 2 months. He reports that he was drinking vodka when he got home from the ED the first time. He admits to having had seizures while withdrawing from alcohol in the past. He tells you that he "just can't help it" and has strong urges to drink, but that he never means "to drink very much." He has had trouble keeping a job over the past several months.

Chart View

Admission Lab Work

Hgb 10.9 g/dL

Hct 23%

ALT (formerly SGPT) 69 units/L

AST (formerly SGOT) 111 units/L

GGT 75 units/L

ETOH 291 mg/dL

1. Please do a SBAR for this patient

Answer 1

SBAR for J.G.

S SITUATION	· J.G,49-year-old man after discharged from emergency department 4 days back again admitted to ED 12 hours ago with an active gastrointestinal (GI) bleed and is being admitted to the intensive care unit (ICU) · His diagnosis is upper GI bleed and alcohol intoxication. His admission vital signs (VS) on admission were 84/56, 110, 26, and he was vomiting bright red blood. · Admission Lab Work Hgb 10.9 g/dL Hct 23% ALT (formerly SGPT) 69 units/L AST (formerly SGOT) 111 units/L GGT 75 units/L ETOH 291 mg/dL
B BACKGROUND	J.G., a 49-year-old man, admitted in emergency department 4 days ago, diagnosed with alcohol intoxication, and released after 8 hours to his brother's care. He was given IV fluids and transfused 6 units of packed red blood cells (PRBCs) in the ED
A ASSESSMENT	VS are blood pressure 154/90, 110, 24 He has a slight tremor in his hands, and appears anxious. He complains of a headache and appears flushed. He has not had any emesis and has not had any frank red blood in his stool or melena (black tarry stools) over the past 5 hours. He denies taking alcohol but later admit to drinking approximately a fifth of vodka daily for the past 2 months. He reports he drunk vodka when he got home from the ED the first time. He admits to having seizures while withdrawing from alcohol in the past. He have the urge to drink again, and also have trouble keeping job over the past several months.
R RECOMMENDATION	Need to education the patient about her health condition. Encouraged him to avoid drinking alcohol. He should be explained properly and make him understand if he take alcohol continuously what can be the complications. He need to change his behaviours. Provide psychological support to stay strong and tae necessary treatment. Inform physicain about his conditions. .