Key elements written in red, with bold and italics.

I – Hello Dr Consultant my name is ___, and I am a JMO in ED.

S – I have just reviewed Ashley, a 17-year-old girl with suspected coeliac disease, who presented with a 3-month history of progressively worsening diarrhoea, worst in the past 4, with associated bloating and abdominal pain.

B – She has no significant medical history. In her family history her mother has Type 1 diabetes and her sister has Hashimoto’s but no history of IBD. On examination she had signs of anaemia and mild abdominal distension. A full blood count showed microcytic anaemia and iron studies showed iron deficiency. A stool culture was normal. Coeliac serology was positive. A gastroduodenoscopy and histological examination showed typical changes suggestive of coeliac disease.

A – I believe Ashley has coeliac disease.

R – I recommend she sees a dietitian and receives education regarding lifelong adherence to a gluten-free diet and receives oral/intravenous iron supplementation.

Needed to win

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

1. At least 2 out of 3 symptoms and signs: abdominal pain, bloating, diarrhoea
2. Anaemia (including either microcytic anaemia or iron deficiency on iron studies)
3. Coeliac serology AND/OR gastroscopy/gastroduodenoscopy
4. Diagnosis of coeliac disease
5. Lifelong gluten-free diet, iron supplementation