Key elements are written in red, with bold and italics.

I – Hello, I am ______, a GP.

S – I have reviewed Mike Simpson, a 64 year-old man with suspected heart failure secondary to ischaemic heart disease.

B – Mike presented with a 3-month history of progressive exertional dyspnea, fatigue, reduction in exercise tolerance and bipedal oedema. He has no other respiratory symptoms. His past medical history includes a myocardial infarction two years ago managed with stenting and hypertension. He takes aspirin, atenolol, ramipril and GTN spray as needed. He is a current smoker with an approximate 30 pack year history.

A – On examination he was hypertensive to 150/85. He had clinical signs of heart failure including pitting oedema to the mid shins, bi-basal crackles, elevated JVP. Bloods revealed a raised BNP and a chest XR showed cardiomegaly. An echocardiogram showed left ventricular dysfunction with reduced ejection fraction. My assessment is that Mike has heart failure with reduced ejection fraction secondary to ischaemic heart disease.

R – My recommendation is for referral to a cardiologist, lifestyle change (smoking cessation, diet, hypertension), pharmacological management including diuresis, and engagement with a cardiac rehabilitation program.

Needed to win

Need to include all 5 sections of ISBAR, plus mention at least four of the following:

1. Presentation with exertional dyspnea, fatigue and lower limb oedema
2. Past history features: previous myocardial infarction, hypertension, current smoker
3. Examination findings identified: hypertension, elevated JVP, displaced apex beat, lung bi-basal crackles, pitting oedema
4. Echocardiogram showed reduced ejection fraction.
5. Heart failure secondary to ischaemic heart disease.