NR305 Week 7 iHuman: Anthony James - Complete
Multi-System Assessment & SBAR Exam Solution
1. PATIENT BIODATA & REASON FOR ENCOUNTER
Data Point Information
Patient Name Anthony James
Age 72 years old
Gender Male
Admission Status Palliative Care Unit
Primary Caregiver Shelly (daughter)
,Data Point Information
Religion Catholic
Reason for Encounter Uncontrolled pain at end of life; metastatic bladder cancer; symptom managem
2. CASE INTRODUCTION
Anthony James is a 72-year-old male admitted to the palliative care unit for
management of uncontrolled pain and end-of-life symptoms related to metastatic
bladder cancer. He was diagnosed with bladder cancer eight months ago and
transitioned to hospice care after radiation therapy failed to improve his prognosis. The
patient has progressively declined over the past week, with decreased oral intake,
increased restlessness, and inability to communicate effectively. His daughter, Shelly,
serves as his primary caregiver and provides historical information.
3. CHIEF COMPLAINT
Patient's Statement (via daughter): "He is in a lot of pain and seems so restless and
uncomfortable. He hasn't been eating or drinking much this past week."
4. QUESTIONS AND ANSWERS DURING FULL HISTORY
Q: When did the symptoms start?
A: The increased restlessness and decreased oral intake began approximately one week
ago.
Q: What is the pain level?
A: Patient is unable to self-report pain due to decreased level of consciousness, but
daughter reports visible signs of discomfort and restlessness.
,Q: Has there been any change in breathing?
A: Daughter notes increased work of breathing and periods of labored respiration.
Q: Is the patient on any medications?
A: Patient is receiving hospice care with morphine for pain management.
Q: Has the patient been eating and drinking?
A: Gradually stopped taking food and fluids by mouth over the last week.
Q: What is the patient's code status?
A: Patient is on hospice/palliative care with DNR/DNI status per family wishes.
Q: Who is the primary decision-maker?
A: Daughter Shelly is the primary caregiver and decision-maker.
5. HISTORY
Component Details
Source Daughter (Shelly) - patient unable to communicate
Reliability Reliable historian
Age 72 years
Gender Male
Marital Status Not specified
Occupation Not specified
Religion Catholic
, 6. HISTORY OF PRESENT ILLNESS (HPI)
Anthony James is a 72-year-old male with a history of metastatic bladder cancer
diagnosed eight months ago. Initial treatment included radiation therapy; however,
when this failed to improve his prognosis, the family made the decision to transition to
hospice care to focus on quality of life.
Over the past week, the patient has experienced:
Progressive decrease in oral intake - gradually stopped taking food and fluids by
mouth
Increased restlessness - visibly uncomfortable, unable to settle
Decreased level of consciousness - not responsive to questions
Signs of uncontrolled pain - despite current pain management regimen
Labored breathing - increased respiratory effort
The patient was admitted to the palliative care unit for symptom management with the
goal of eventual discharge home if possible. He has been visited by case management
and pastoral care.
7. REVIEW OF SYSTEMS (ROS)
GENERAL
Severe fatigue, weakness
Progressive decline in functional status
Decreased level of consciousness
NEUROLOGICAL
Decreased responsiveness
Increased restlessness
Unable to communicate effectively
RESPIRATORY
Multi-System Assessment & SBAR Exam Solution
1. PATIENT BIODATA & REASON FOR ENCOUNTER
Data Point Information
Patient Name Anthony James
Age 72 years old
Gender Male
Admission Status Palliative Care Unit
Primary Caregiver Shelly (daughter)
,Data Point Information
Religion Catholic
Reason for Encounter Uncontrolled pain at end of life; metastatic bladder cancer; symptom managem
2. CASE INTRODUCTION
Anthony James is a 72-year-old male admitted to the palliative care unit for
management of uncontrolled pain and end-of-life symptoms related to metastatic
bladder cancer. He was diagnosed with bladder cancer eight months ago and
transitioned to hospice care after radiation therapy failed to improve his prognosis. The
patient has progressively declined over the past week, with decreased oral intake,
increased restlessness, and inability to communicate effectively. His daughter, Shelly,
serves as his primary caregiver and provides historical information.
3. CHIEF COMPLAINT
Patient's Statement (via daughter): "He is in a lot of pain and seems so restless and
uncomfortable. He hasn't been eating or drinking much this past week."
4. QUESTIONS AND ANSWERS DURING FULL HISTORY
Q: When did the symptoms start?
A: The increased restlessness and decreased oral intake began approximately one week
ago.
Q: What is the pain level?
A: Patient is unable to self-report pain due to decreased level of consciousness, but
daughter reports visible signs of discomfort and restlessness.
,Q: Has there been any change in breathing?
A: Daughter notes increased work of breathing and periods of labored respiration.
Q: Is the patient on any medications?
A: Patient is receiving hospice care with morphine for pain management.
Q: Has the patient been eating and drinking?
A: Gradually stopped taking food and fluids by mouth over the last week.
Q: What is the patient's code status?
A: Patient is on hospice/palliative care with DNR/DNI status per family wishes.
Q: Who is the primary decision-maker?
A: Daughter Shelly is the primary caregiver and decision-maker.
5. HISTORY
Component Details
Source Daughter (Shelly) - patient unable to communicate
Reliability Reliable historian
Age 72 years
Gender Male
Marital Status Not specified
Occupation Not specified
Religion Catholic
, 6. HISTORY OF PRESENT ILLNESS (HPI)
Anthony James is a 72-year-old male with a history of metastatic bladder cancer
diagnosed eight months ago. Initial treatment included radiation therapy; however,
when this failed to improve his prognosis, the family made the decision to transition to
hospice care to focus on quality of life.
Over the past week, the patient has experienced:
Progressive decrease in oral intake - gradually stopped taking food and fluids by
mouth
Increased restlessness - visibly uncomfortable, unable to settle
Decreased level of consciousness - not responsive to questions
Signs of uncontrolled pain - despite current pain management regimen
Labored breathing - increased respiratory effort
The patient was admitted to the palliative care unit for symptom management with the
goal of eventual discharge home if possible. He has been visited by case management
and pastoral care.
7. REVIEW OF SYSTEMS (ROS)
GENERAL
Severe fatigue, weakness
Progressive decline in functional status
Decreased level of consciousness
NEUROLOGICAL
Decreased responsiveness
Increased restlessness
Unable to communicate effectively
RESPIRATORY
