Sample handover
Kyle Jennar
Key elements are written in red, with bold and italics.
I – Hello, I am ______, a GP.
S – I have just reviewed Kyle, a 63-year-old man with paroxysmal atrial fibrillation who came to see me following a three-month history of repeated episodes of fatigue, dizziness, shortness of breath on exertion, and palpitations. While initially sporadic, the episodes are increasing in frequency, and particularly debilitating.
B – Kyle’s past medical history is significant for controlled hypertension, gastroesophageal reflux, 7.5 pack-years smoking history, significant alcohol consumption of approximately 25-28 standard drinks per week. Family history of coronary artery disease. On examination, lateral displacement of apex beat, no signs of heart failure, tachycardia and irregularly irregular pulse. An ECG showed atrial fibrillation, and a rapid ventricular response, with rate of 130bpm. An echocardiogram showed moderate mitral regurgitation, likely due to left ventricular hypertrophy, increased size of left atrium and a thrombus in the left atrial appendage.
A – After reviewing Kyle my assessment is he has paroxysmal atrial fibrillation. Due to existing thrombus in the left atrium, CHA₂DS₂-VASc 3 – anticoagulation indicated.
R – I recommend Kyle commences treatment with beta-blockers to control rate, and anticoagulation to lower stroke risk. Refer to cardiology for further investigations and ongoing management, including smoking cessation and alcohol reduction counselling.
Needed to win
Need to include all 5 sections of ISBAR, plus mention at least four of the following:
- Identification of repeated episodes of at least 3 of the following symptoms: fatigue, dizziness, palpitations, exertional dyspnea.
- Mention at least 3 of the following cardiac risk factors: hypertension, smoking, alcohol consumption, family history.
- Mention physical examination findings of tachycardia and irregularly irregular pulse.
- Mention ECG findings of atrial fibrillation with tachycardia.
- Mention treatment (rate control and anticoagulation) or refer to cardiology.
