Teaching Plan SBAR 11_14

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Lone Star College System, Woodlands *

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MISC

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Medicine

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Jan 9, 2024

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docx

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1 Teaching Plan / SBAR Caitlin Thomas Chamberlain University NR: 447 Community Health Heaven Simms MBA DNP RN FCM PHNA-BC NE-BC November 14, 2023

2 SBAR Situation: GL is a 61-year-old female patient presenting to the perioperative evaluation and management department on 10/31/2023 at 10:00 for a preoperative evaluation for a double mastectomy scheduled on 11/04/2023. The primary medical diagnosis is infiltrating ductal carcinoma of lower inner quadrant of right female breast. Patient has no known allergies. There are no advanced directive documents on file, no isolation precautions ordered. Patient has completed the pre-anesthesia questionnaire, and answer were reviewed and confirmed correct with the patient. Patient has standard HIPPA code ordered. Physician is Dr. Sumaira. There are no activity modifications for this patient at the moment as patient ambulates well and is a low fall risk. Vital signs are as follows: B/P: 129/30 HR: 86 RR: 16 T: 98.7 F oral O2 Sat: 99% room air. Patient had consult with plastic surgery at 0840 on 10/31/2023 prior to appointment with POEM. The patient speaks Spanish, and requires an interpreter or Spanish speaking provider. Background: Medical HX: Disorder of the thyroid gland 01/10/2010. Rheumatoid arthritis 01/10/2010 Menopause: 06/15/2021 Diverticulitis 08/01/2021 Cyst of breast 02/06/2023 Malignant tumor of right breast 03/13/2023 Significant Family Medical HX: Lymphoma- maternal grandmother- deceased Uterine Cancer- Mother- Deceased at age 72 Other- Father- Deceased at age 72 Tongue cancer- maternal cousin- deceased at age 28 Current medications: 11/11/2023 Ibuprofen (Advil, Motrin) 800 mg tab PO Q8H 11/09/2023 Doxycycline (VIBRAMYCIN) 100 mg tab PO BID 11/08/2023 Tramadol (ULTRAM) 50 MG tab PO Q6H PRN

3 11/08/2023 Acetaminophen (TYLENOL) 325 Mg tab PO Q6H PRN 11/07/2023 Lidocaine-prilocaine (EMLA) 2.25% cream 1 application 08/07/2023 Levothyroxine (SYNTHROID) 112 mcg tab PO DAILY BEFORE BREAKFAST 07/30/2023 Atorvastatin (LIPITOR) 10 mg tab PO at bedtime 07/30/2023 Ondansetron (ZOFRAN) 8 mg tab PO Daily for 3 days after chemotherapy treatment then 1 tab Q8H PRN 07/30/2023 Pantoprazol (PROTONIX) 40 mg EC TAB PO DAILY Unknown date: Temazepam (RESTORIL) 30 mg CAPSULE PO DAILY AT BEDTIME Unknown date: Cetirizine (ZYRTEC) 10 Mg tab PO DAILY PRN Allergies : NKDA History of present illness/primary medical diagnosis: 02/17/2022 OSI screening mammogram: focal asymmetry in the left breast at 12:00 02/24/2023 OSI diagnostic mammogram: mass in right breast lower inner aspect anterior depth 02/24/2023 OSI US: 1.5 cm mass in right breast at 4:00 middle depth 4 cm FN 03/06/2023 OSI diagnostic mammogram: mass in the right breast at 4:00 middle depth 03/06/2023 OSI Ultrasound guided biopsy: right breast, 4:00. Invasive ductal carcinoma, intermediate grade, ER 0%, PR 0%, HER-2 score 0 Ki-67 90% 03/31/2023: INITIAL DIAGNOSIS: infiltrating ductal carcinoma of lower inner quadrant of right female breast. 03/31/2023: BILATERAL DIAGNOSTIC MAMMOGRAM 3D WITH CONTRAST: RIGHT BREAST:  Obscure mass with central necrosis measuring 2.6 cm at 4-5:00 position, 6mm FN. Outside pathology revealing IDC  Mild skin thickening along the inferior aspect of the right breast representing post biopsy changes LEFT BREAST:  In the left breast, no dominant mass, distortion, or suspicious calcifications, enhanced mass or non-mass enhancement are identified. 03/31/2023: RIGHT BREAST/NODAL BASINS ULTRASOUND

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