SBAR 2

[admin]

Stem:
You are the surgical SHO working in the general surgery department 4G ward at St Bartholomew’s hospital, London. Mrs. Eleanor Thompson, DOB: 15/06/1942 has been admitted for right-sided simple mastectomy and axillary lymph node clearance, the operation is uneventful, and a drain is inserted, postoperatively she has developed axillary swelling, discomfort and is short of breath, please update the consultant Mr. Mann about her current condition and ask for advice.

[admin]

PATIENT NOTES – For Candidate Reading (9 minutes)
Date: 4th April 2020
Patient Details
Name: Mrs Eleanor Thompson
DOB: 15/06/1942 (Age 77)
Sex: Female
Admission Date: 2nd April 2020
Consultant: Mr Mann
Location: General Surgery Ward 4G

Surgery Performed: Right breast mastectomy with axillary lymph node clearance (levels I & II)
Past Medical History
Chronic Obstructive Pulmonary Disease (moderate)
Mild Left Ventricular Failure (LVF)
Hypertension
No known drug allergies

Operation Note (2nd April 2020)
Indication: Right breast invasive ductal carcinoma
Procedure:
Elliptical incision made
Entire breast tissue excised en bloc
Axillary lymph node clearance levels I & II
One suction drain inserted
Wound closed in layers
Estimated Blood Loss: 150 mL

Intraoperative Complications: None
Postoperative Course
POD1 (3rd April 2020):
Temp: 36.9°C
Drain output present
POD2 (4th April 2020 – Today):
Temp: 37.2°C (rising from 37.0 and previously 36.9)
Symptoms:
New right axillary swelling
Local discomfort
Mild shortness of breath (SOB)
Exam findings:
Axilla swollen, mildly tender
Drain: no output recorded today
Pain: Mild, controlled with standard analgesia
Resp: Mild SOB; no wheeze; sats stable (assume normal unless you want specific values added)

Most Recent Bloods (4th April 2020)
WCC: 10.2
Hb: 11.5 g/dL
Platelets: 230
(UEs and CRP not supplied in stem)
Social / Discharge Context
Lives 60 miles from hospital

High risk for early discharge due to:
Age
COPD
Mild LVF
Distance from hospital
Daughter requesting discharge against medical advice (DAMA)
Daughter is a teacher
Needs to provide childcare for two teenagers + toddler
Pressing for “taking mum home today”
Assessment (Ward SHO)
POD2 post right mastectomy + axillary node clearance with:
New axillary swelling
No drain output
Mild SOB
→ Concern for early postoperative complication (e.g., seroma, haematoma, early infection, or drain blockage)
Patient otherwise haemodynamically stable but not suitable for early discharge due to postoperative concerns and comorbidities.
Requires senior review.

[admin]

S — Situation
“Hello, it’s David, the SHO on Ward 4G. I’m calling about Mrs Eleanor Thompson, DOB 15/06/1942, who is post-operative day 2 following a right mastectomy with axillary lymph node clearance.
She has developed new right axillary swelling, discomfort, and mild shortness of breath, and I’m concerned about a possible early postoperative complication.”
B — Background
“She has moderate COPD, mild left ventricular failure, and hypertension.
Her surgery two days ago was uneventful with 150 mL blood loss, and a drain was inserted.
Since yesterday, her temperature has been slowly rising from 36.9 to 37.2 today.
Importantly, the drain has had no output today, and the axilla appears swollen and mildly tender.
Her daughter is requesting discharge today due to family childcare pressures, but given the clinical changes I feel this is unsafe.”

A — Assessment
“On examination, she has a swollen right axilla, mild tenderness, and no drain output. Her pain is controlled, and observations are otherwise stable apart from very mild temperature rise.
Her bloods today show: WCC 10.2, Hb 11.5, platelets 230.
My concern is a postoperative seroma, haematoma, or possibly early infection, or a blocked drain.
Given her comorbidities and mild SOB, I also want to rule out cardiopulmonary causes.”

R — Recommendation
“I’d like you to review her urgently, please.
I’d appreciate guidance on whether to:
Attempt drainage (needle aspiration) or re-site/flush the drain,
Start empirical antibiotics,
Arrange ultrasound of the axilla,
And confirm whether you agree she should not be discharged today.
Could you please come to review her on Ward 4G, or advise on the next immediate steps?”