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

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

S – I have seen John Perkins, a 54-year-old man who presented to ED with signs of confusion and drowsiness following a two-day history of dull abdominal pain self-treated with unknown amount of paracetamol, and neuropsychiatric symptoms: confusion, sleepiness.

B – He hasn’t engaged with healthcare in ten years, and has untreated hypertension, and alcohol use disorder (>10 standard drinks per day).

A – On examination, he has numerous signs of chronic liver disease: palmar erythema, Dupuytren’s contracture, gynaecomastia, ascites, caput medusae, jaundice, bruising, scratch marks, muscle wasting, and peripheral oedema. His abdomen is diffusely tender on palpation of left lower quadrant. Abdominal ultrasound showed fibrotic/cirrhotic changes of the liver and signs of portal hypertension. Liver function tests are consistent with chronic liver disease. Paracetamol level is also markedly elevated.

R – I believe this patient is suffering from acute hepatic encephalopathy on a background of chronic liver disease, precipitated by severe constipation and accidental paracetamol overdose. I recommend this patient receives faecal disimpaction, oral lactulose, rehydration, alcohol withdrawal management, and N-Acetyl Cysteine in the short term. Long term, I suggest referral to drug and alcohol services, a dietitian, and social worker, as well as ongoing engagement with medical services.

Needed to win

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

1. Neurological signs and/or neuropsychiatric symptoms, plus abdominal pain, and paracetamol use.
2. Untreated hypertension and alcohol use disorder.
3. At least 4 signs of chronic liver disease identified on physical examination.
4. Abnormal liver function tests and abdominal ultrasound.
5. Acute hepatic encephalopathy on background of chronic liver disease.