Detailed SBAR Notes

Situation

• Healthcare Provider Identification: Dr Sarah Jenkins, General Practitioner, Bayside Family Medical Practice.
• Patient Identification: Arthur Pendelton, 74 yo male, DOB 12/04/1950, Medicare: 2459 87123 1, IHI: 8003608166690503.
• Primary Concern: Acute onset severe dyspnoea, orthopnoea, and productive cough with pink frothy sputum.
• Timeframe of Issue: Symptoms commenced at 04:00 today (14/05/2024) and have progressively worsened over the past 6 hours.
• Current Clinical Status: Patient is sitting upright, visibly distressed, tachypnoeic, and speaking in short phrases. Condition is deteriorating despite initial bronchodilator therapy in the clinic.
• Urgency of the Situation: Medical emergency requiring immediate ED transfer and acute intervention.
• Key Clinical Indicators: BP 168/98 mmHg, HR 118 bpm (irregular), RR 28 /min, SpO2 88 % on RA (improved to 93 % on 6 L/min O2 via Hudson mask), T 36.8 °C.

Background

• Relevant Medical History: HFrEF (LVEF 35 % on 2023 echo), permanent AF, HTN, T2DM, CKD stage 3a.
• Recent Hospitalizations or Procedures: Admitted to Alfred Hospital 3 months ago (02/2024) for NSTEMI and decompensated CCF; had 1x DES to LAD.
• Current Medications:
  • furosemide (Lasix®) 40 mg PO daily (patient admits non-compliance for the past 4 days)
  • bisoprolol (Bicor®) 5 mg PO daily
  • ramipril (Tritace®) 5 mg PO daily
  • apixaban (Eliquis®) 5 mg PO BID
  • dapagliflozin (Forxiga®) 10 mg PO daily
• Recent Laboratory or Imaging Findings: Path (01/05/2024): eGFR 52 mL/min/1.73m2, Cr 115 µmol/L, K+ 4.4 mmol/L, BNP 450 ng/L.
• Allergies or Contraindications: Penicillin (anaphylaxis); NSAIDs contraindicated due to CKD/CCF.
• Baseline Status: Independently mobile with a single-point stick, NYHA Class II dyspnoea at baseline, lives at home with wife.

Assessment

• Clinical Deterioration or Progression: Worsening respiratory distress and hypoxia over the last 30 minutes in the clinic treatment room.
• Objective Findings: JVP elevated at 6 cm above sternal angle. Chest auscultation reveals widespread bilateral inspiratory crackles to the mid-zones and mild expiratory wheeze. Bilateral pitting pedal oedema to the mid-shins. 12-lead ECG shows rapid AF at 118 bpm, old anterior Q waves, no acute ST-segment elevation.
• Failed or Ineffective Interventions: Administered salbutamol (Ventolin®) 5 mg NEB stat at 10:15 with no clinical improvement in work of breathing or SpO2.
• Expected vs. Unexpected Nature of Issue: Expected decompensation given recent furosemide non-compliance and underlying HFrEF.
• Clinical Judgment: Acute cardiogenic pulmonary oedema secondary to decompensated HFrEF and medication non-compliance, complicated by rapid AF.

Recommendation

• Proposed Next Steps: Immediate Priority 1 ambulance transfer to the Emergency Department for acute resuscitation and stabilisation.
• Physician Review or Specialist Consultation: Immediate bedside assessment by the ED Registrar upon arrival, with early Cardiology notification.
• Further Diagnostic Testing: Urgent portable CXR, VBG, FBE, UEC, serial troponins, and repeat ECG on arrival.
• Treatment Adjustments: Administered furosemide 40 mg IV stat and glyceryl trinitrate (Nitrolingual®) 400 µg SL spray in clinic at 10:30. Recommend further IV loop diuretics, consideration of GTN infusion, and rate control for AF in ED.
• Monitoring and Follow-Up Plan: Continuous cardiac monitoring, pulse oximetry, and q15min BP observations during transport. Strict fluid balance with IDC insertion in ED.
• Additional Support Services: Initiate continuous positive airway pressure (CPAP) via ambulance paramedics or immediately upon ED arrival.