Key elements written in red, with bold and italics.

I – Hello, my name is ___ and I am a JMO.

S – I have reviewed Olive Greene, a 58-year-old woman with suspected right middle lobe community acquired pneumonia. She presented to ED with a 3-day history of progressively worsening productive cough, fatigue, and shortness of breath on exertion. This is markedly different from chronic dry cough she has experienced. She had no chest pain, palpitations, or shortness of breath at rest.

B – She has a history of hypertension and a 17.25-pack year smoking history. She has a family history of type 2 diabetes and hypertension. On examination she is febrile, hypertensive, tachypnoeic, and her O2 Sats is 95% on room air. On auscultation of the chest, there are prominent crackles over the right middle zone. An ECG was normal, and a chest X-ray showed right middle lobe consolidation. A FBC shows raised neutrophils. Sputum MCS showed Gram positive diplococci, with culture and sensitivity tests pending.

A – I believe Olive has community acquired lobar pneumonia, likely due to S. Pneumoniae, without complicating factors requiring admission.

R – I recommend she is prescribed oral amoxicillin therapy and discharged home, with follow-up in 48 hours by her GP.

Needed to win

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

1. At least 2 of the 3 symptoms: productive cough, fatigue, dyspnoea.
2. At least 3 of the 4 signs on physical examination: fever, hypertension, tachycardia, right middle lobe crackles.
3. At least 2 of 4 test results: ECG, FBC, CXR, Sputum MCS.
4. Lobar/Right middle lobe pneumonia.
5. Antibiotic therapy and discharge home.