Sample handover
James Nguyen
Key elements are written in red, with bold and italics.
I – Hello, my name is ___ and I am a JMO.
S – I have seen a 17yo male, James Nguyen, who has a moderate left-side spontaneous pneumothorax but is currently stable.
B – He presented following sudden onset of chest pain and shortness of breath. The chest pain is pleuritic in nature, with a sharp quality and worsening on inspiration. He has ongoing shortness of breath at rest, though his saturation is stable at 95% on room air. He is currently tachycardic, tachypnoeic, and using accessory muscles to breathe. He has no significant past medical or social history, doesn’t smoke, however he is tall and slim, with potential familiarity for connective tissue disease.
A – A chest X-Ray showed moderate left sided pneumothorax. There is no sign of tension pneumothorax, as the trachea is not deviated, there is no mediastinal shift, there is no JVP elevation, and the patient is haemodynamically stable. An ECG showed sinus tachycardia, with no signs of ischaemia.
R – I recommend the patient is reviewed by a senior clinician, for decision between monitoring and repeat of Chest X-Ray vs positioning of chest drain.
Needed to win
Need to include all 5 sections of ISBAR, plus mention at least four of the following:
- Sudden onset of sharp chest pain, worsening on inspiration, and shortness of breath
- Tachypnoea, tachycardia, use of accessory muscles, but good oxygen saturation
- Left-sided pneumothorax. No evidence of tension pneumothorax
- Potential familiarity for connective tissue disease, no other relevant medical history.
- Review by a senior clinician.