Physician Assistant

Physician Assistant

PHYSICIAN/

PHYSICIAN ASSISTANT

COMPLETED SBAR

PHYSICIAN/PHYSICIAN ASSISTANT SBAR

Learning Objectives:

• Describe the value of interprofessional communication for your profession and your

clients/patients

• Effectively communicate to another profession your professional insight (e.g. multi-

factorial nature of fall risk, risks related to neuropathy) about this patient using

SBAR

S (Situation):

An 82 year old widow is seen in your primary care office for an urgent visit. Your patient/client’s daughter is visiting from out of town and accompanies her to the appointment. The patient's daughter is concerned because upon arrival last night, she noticed both a contusion and laceration on the patient's left arm. Her mother admits that she has had a series of falls.

B (Background):

HPI The patient reports that she had fallen in her kitchen the day before while emptying the dishwasher and on further questioning admits to additional falls in the bathroom and in the garden within the last month. She describes a sense of imbalance before the falls and falls occur while she is bending or turning. She denies dizziness or a spinning sensation and does not “black out”. She simply is unable to right herself once she feels like she is going over. She does frequently feel a little dizzy going from lying down to standing up and from sitting to standing

Past Medical History: High blood pressure, Type 2 diabetes, gastroparesis

Review of Systems: (positives only)Gen: appetite is less, it’s no fun ‘cooking for one’, sleeps alright, but never has been a good sleeper; weight has declined 10 pounds in the last 2 years; ENT: feels dizzy if she gets up too quickly; has neglected dental care in the last 3 years during her husband’s illness; GI: food can get “stuck” especially dry foods like bread, and she coughs during meals; also she can experience nausea if she eats too quickly.

Medications: HCTZ, glipizide, metachlopramide

Social History: she has a 12th grade education and worked as a salesperson until her retirement at age 65. She was married for 55 years. She and her husband had three children all of whom survive, but none of whom live locally. She has never smoked and rarely drinks alcohol. Physical Exam: Blood Pressure 160/70 seated with heart rate 70 and 130/60 standing at 2 min. with heart rate 80, respiratory rate 18, weight 115 pounds, height 63 inches

HEENT: several missing teeth and periodontal caries, dry mucous membranes. Eyes: visual acuity using 20/80 right, 20/100 left with correction. Ears: fails the whisper test bilaterally, impacted cerumen bilaterally. Neck: negative. Chest: clear. Cardiovascular: regular rate and rhythm, full pulses no bruits. Abdomen: soft, nontender; stool heme test negative. Musculoskeletal: notable for crepitation and decreased range of motion at the knees bilaterally. Neurologic: (positives only) bilateral hip flexor weakness, diminished vibratory sense to the knee bilaterally; mild cogwheeling at the bilateral wrists; cognitive screen with the Mini-Cog is negative ; she fails the up and go, gait is slightly short stepped, and broad-based; unsteady on turns, easily retropulsed to a gentle sternal nudge.

Lab studies come back showing:

SCr: 1.2 (0.44-1.03mg/dL)

BUN: 27 (6-20mg/dL)

K: 4.0 (3.6-5.1mmol/L)

Na: 140 (136-145mmol/L)

HemoglobinA1c: 6.2 (4.0-6.0%)

Hemoglobin: 11.4 (11-15.1 g/dL)

WBC: 6.2 (4.0-11.0 X 103/uL)

A (Assessment):

Abnormality of gait with falls. Multiple falls and fall with injury means a multidimensional falls assessment is needed.

  1. Peripheral neuropathy (large axonal pattern) which is likely contributing to the gait disorder.
  2. Hypertension with orthostatic hypotension. Patient may be slightly dehydrated on exam.
  3. Weight loss
  4. Oral dental disease

R (Recommendation):

  1. Ask pharmacy for medication review and recommendations.
  2. PT evaluate and treat gait disorder.
  3. Lab studies to look for treatable causes of the neuropathy.
  4. Check BUN and creatinine. Ask that she take in 1.5 liters of fluids daily.
  5. General physical exam does not suggest serious underlying medical cause of weight loss. Will complete screening with THS (thyroid function); CBC; CMP. She is a nonsmoker so Chest X-ray not needed. Ask RD to assess adequacy of diet.
  6. Ask that she see her dentist ASAP.
  7. Consider Occupational therapy consultation for home safety evaluation.
  8. Social work please assess resources for support in her home.
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