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¶ … individual health history and examination of a 61-year-old American male Vietnam veteran, "Mr. John Veteran" using the SBAR approach. Mr. Veteran is married, with two adult children and three grandsons, aged 4, 7 and 12 years by his older daughter who is a registered nurse in an intensive care unit; his younger daughter is a senior in college majoring in business administration (she received a full scholarship to a private college). Mr. Veteran earned his bachelor's degree in organizational leadership at a small midwestern university. Although Mr. Veteran continues to work full time as a paralegal, he advises that he intends to "semi-retire" when he turns 62 years next year and becomes eligible for Social Security payments. Mr. Veteran smokes two packs of cigarettes a day and drinks beer on occasion, but does not take drugs, even for severe pain, because he is worried about becoming addicted to them.
Although he served as a combat veteran in Vietnam, Mr. Veteran finished his tour of duty without incident. He was, however, wounded in 1976 while serving in Belgium at Supreme Headquarters Allied Powers Europe when his car struck a light stanchion on the autobahn, seriously injuring him with two broken ankles, severe traumatic brain injury, a broken right femur, a fractured pancreas and a broken mandible. Mr. Veteran has undergone 17 orthopedic surgeries over the years to repair these injuries, including a left femoral shortening by 1-1/2 inches to even his...
Mr. Veteran had an artificial joint installed in his right ankle initially, but this failed after 2 years at which time his ankle was fused using a piece of bone harvested from his right iliac crest. Mr. Veteran is otherwise in good health.
Mr. Veteran is rated 90% disabled by the Department of Veterans Affairs but the veteran has been appealing this rating for several years in an attempt to secure a 100% total and permanent rating. Mr. Veteran concedes he may be suffering from posttraumatic stress disorder as well but has not sought service-connection for this condition because he is worried that the application process would exacerbate this condition further without helping his VA appeal. The veteran reports that the 100% disability rating pays nearly twice what his current rating provides, as well as healthcare insurance for his wife and younger daughter while she is attending college full time. In addition, if he can secure a 100 rating, he can use services on military bases such as commissaries and post/base exchanges.
SBAR Analysis
Situation:
Healthcare site: The healthcare site is the Department of Veterans Affairs Medical Center in Oklahoma City, Oklahoma which provides Mr. John Veteran's medical care.
Date: May 31, 2014
Problem/Issue: Mr. Veteran is a 90 disabled veteran with a number of residual…
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