KFP – Aboriginal and Torres Strait Islander Health

Pauline Winton, aged 36, is a Gamilaraay woman who presents to your remote Aboriginal Medical Service (AMS) for follow-up after a recent hospital discharge for gestational diabetes mellitus (GDM). She is currently 32 weeks pregnant with her fourth child. Her previous pregnancies were complicated by pre-eclampsia and low birthweight infants. Pauline expresses concerns about ‘big baby stories’ in the community and wants to avoid another hospital birth if possible.

Medications: Metformin 500 mg BD, Ferrous sulfate 325 mg daily

Allergies: Nil known

Past history: GDM (current), pre-eclampsia (previous pregnancy), anaemia in pregnancy

Family history: Mother with type 2 diabetes and hypertension

Social history: Lives with extended family, smokes 5 cigarettes per day, no alcohol or other drugs, limited transport to clinic, access to bush nurse monthly

Obstetric/sexual history: Gravida 4 Para 3, all vaginal deliveries, history of low birthweight babies

Psychiatric history: Nil recorded, but reports ‘worrying a lot’ this pregnancy

Preventative Healthcare: Antenatal care shared with GP and AMS midwife; no recent Pap smear

Examination findings: BP 126/78 mmHg, fundal height 34 cm, fetal HR 142 bpm, no oedema, urine dipstick: trace protein, glucose +

Investigations: HbA1c 6.5%, Ferritin 19 mcg/L (normal 30–300), OGTT showed fasting 5.5 mmol/L, 2-hr post-glucose 9.5 mmol/L

What are the most appropriate next steps in her care? Select four (4) from the following list:

Trevor Bani, a 52-year-old Torres Strait Islander man, presents to your urban Aboriginal Community Controlled Health Service (ACCHS) for review of his ongoing fatigue, weight loss, and worsening lower limb numbness over several months. He has recently moved from Thursday Island to Brisbane to be closer to family. He is known to have poorly controlled type 2 diabetes mellitus (T2DM).

Medications: Metformin 1000 mg BD, Gliclazide MR 120 mg daily, Atorvastatin 40 mg nocte, Perindopril 5 mg daily

Allergies: Nil known

Past history: T2DM for 10 years, chronic kidney disease (eGFR 62), hypertension, dyslipidaemia

Social history: Lives with daughter and grandchildren, unemployed, minimal physical activity, diet high in refined carbohydrates. Smokes 15 cigarettes/day, drinks 2–3 standard drinks on weekends

Examination findings: Weight 108 kg, BMI 33 kg/m², BP 136/84 mmHg, reduced pinprick and vibration sensation below the knees bilaterally, monofilament test absent over plantar surfaces. No foot ulcers or deformities noted. Fundoscopy shows background diabetic retinopathy

Investigations:
HbA1c 9.2% (target <7.0%)
eGFR 58 mL/min/1.73m² (normal >90)
Urine ACR 12.1 mg/mmol (normal <2.5)
Lipids: TC 4.2, HDL 0.8, LDL 2.1, Trig 3.5 mmol/L

What are the most appropriate next steps in Trevor’s management? Select four (4) from the following list:

Megan Warlpiri, a 23-year-old Warlpiri woman, presents to your rural general practice for a routine health check. She reports general tiredness, heavy periods, and some dizziness when standing. She moved to town recently from a remote community and hasn’t accessed health services regularly in the past. She is not currently pregnant and is not using contraception. Megan is caring for her younger siblings and lives with extended family in overcrowded housing.

Medications: Nil

Allergies: Nil known

Past history: Nil recorded

Social history: Smoking 10 cigarettes/day, no alcohol, limited dietary intake (mostly bread, tea, processed meats). No regular GP. Not working. No access to private transport

Examination findings: Pale conjunctivae, BMI 18.9, BP 96/62 mmHg, HR 104 bpm, soft systolic murmur at left sternal edge, otherwise normal cardiorespiratory exam

Investigations:
FBC: Hb 78 g/L (115–160), MCV 72 fL (80–96), Ferritin 7 µg/L (30–300)
Beta-HCG: Negative
STI screen: Pending
Urine PCR: Negative

What are the most appropriate next steps in Megan’s management? Select three (3) from the following list:

Joseph Puruntatameri, a 45-year-old Tiwi Islands man, presents to your remote clinic with persistent cough, weight loss, and intermittent fevers over the last three months. He also reports night sweats and a general feeling of being unwell. He has a history of smoking (20 cigarettes/day), hazardous alcohol use, and previously treated pulmonary tuberculosis (TB) 12 years ago. He is concerned the TB has come back.

Medications: None

Allergies: Nil known

Past history: Pulmonary TB (successfully treated), chronic hepatitis B carrier, alcohol-related liver disease

Social history: Lives in overcrowded housing with extended family. Has not worked in over 10 years. Access to health care is limited to fortnightly fly-in GP and on-site Aboriginal Health Practitioner

Examination findings: Temp 37.9°C, RR 20, HR 98, SpO₂ 96% RA. Thin appearance. Bilateral crackles in upper zones. No clubbing or lymphadenopathy. No hepatosplenomegaly

Investigations: FBC: Hb 112 g/L (130–180), WCC 9.8 ×10⁹/L (4–11), Platelets 420 ×10⁹/L (150–400)
CRP: 58 mg/L (<5)
LFTs: mildly elevated ALT and GGT
CXR: Bilateral apical opacities with cavitation (see image)
Sputum AFB: pending

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What are the most appropriate next steps in Joseph’s care? Select three (3) from the following list:

Ashley Doolan, a 15-year-old Yorta Yorta girl, presents with her grandmother to your general practice in a regional town. She reports a 3-month history of painful, itchy sores on her lower legs that ‘won’t heal properly’. Her grandmother reports that Ashley is shy about attending school due to teasing about the smell. Ashley has a history of eczema and recurrent skin infections. She has not received regular primary care in recent years and hasn’t had any immunisations since age 5.

Medications: Nil

Allergies: Nil known

Past history: Eczema, recurrent impetigo

Social history: Lives with grandmother and cousins, household overcrowded, inconsistent access to running water, limited access to school nurse

Examination findings: Multiple crusted, exudative lesions on both lower legs, some with surrounding erythema. Mild fever (37.8°C), pulse 88 bpm, no systemic signs. Mild scratching and excoriation of surrounding skin

Investigations: Swab of lesion: pending
CRP 18 mg/L (<5)
FBC: WCC 10.4 ×10⁹/L, Hb 116 g/L
No signs of renal involvement clinically

What are the most appropriate next steps in Ashley’s management? Select four (4) from the following list:

Clifford Watego, a 61-year-old Bundjalung man, presents to your urban ACCHS clinic with worsening shortness of breath, fatigue, and weight gain over several months. He has been hospitalised twice in the past year for ‘fluid on the lungs’. He lives alone in social housing and struggles to afford medications consistently. He smokes 10 cigarettes per day and drinks alcohol most weekends. He is known to have type 2 diabetes, hypertension, and ischemic heart disease.

Medications: Irbesartan 150 mg daily, Metformin 1 g BD, Aspirin 100 mg daily, Frusemide 20 mg daily (not taken regularly)

Allergies: Nil known

Past history: T2DM, hypertension, NSTEMI 3 years ago, chronic kidney disease (eGFR 55)

Social history: Lives alone, limited transport, Centrelink income, recent bereavement of partner

Examination findings: Temp 36.8°C, HR 92 bpm, BP 138/82 mmHg, SpO₂ 94% RA. Bibasal crackles, mild pedal oedema, raised JVP

Investigations: ECG: Sinus rhythm, left ventricular hypertrophy
BNP: 890 pg/mL (<100)
HbA1c: 8.6%
UEC: Creatinine 122 µmol/L, eGFR 48, K⁺ 4.9 mmol/L

What are the most appropriate next steps in Clifford’s management? Select four (4) from the following list:

Denise Yarran, a 26-year-old Noongar woman, presents to your inner-city clinic for a mental health review. She was recently discharged from the local hospital following a suicide attempt via medication overdose. Denise reports ongoing feelings of hopelessness, difficulty sleeping, and ‘a heavy feeling in her chest every day’. She left her job two months ago and has been disengaged from family and community. She experienced domestic violence in a previous relationship and has a history of alcohol misuse. Denise has been reluctant to attend follow-up appointments and states she ‘doesn’t trust doctors’.

Medications: Nil current. Discharged with a prescription for sertraline 50 mg daily (not commenced)

Allergies: Nil known

Past history: Depression, anxiety, prior hospitalisation for suicidal ideation, alcohol misuse, PTSD features (not formally diagnosed)

Social history: Lives alone, unemployed, disconnected from family supports, some financial stress. Cultural identity important but feels ‘disconnected from mob’

Examination findings: Flat affect, low tone, poor eye contact, but cooperative. No acute suicidality today. Denies current alcohol or drug use. Vitals stable

Investigations: Recent bloods within normal limits, urine drug screen negative. No current risk of self-harm noted on formal mental health risk assessment

What are the most appropriate next steps in her care? Select four (4) from the following list:

Patrick Dhurrkay, a 6-year-old Yolŋu boy, presents with his mother to your regional general practice with concerns about his hearing. His teacher has noticed he often asks for questions to be repeated and seems to lose focus in class. Patrick has had several episodes of ear infections in the past, and his mother says he has frequent ear discharge, especially after swimming. He lives in a household with 11 other family members. He has missed several specialist appointments due to transport issues.

Medications: Nil

Allergies: Nil known

Past history: Recurrent otitis media, delayed speech milestones, no known developmental diagnosis

Social history: Lives in overcrowded public housing, attends local primary school, no access to car

Examination findings: Afebrile. Weight and height appropriate. Otoscopy: Right ear with purulent discharge, left ear with dull, retracted tympanic membrane. No mastoid tenderness

Investigations: Audiometry shows bilateral conductive hearing loss, more severe on the right

What are the most appropriate next steps in Patrick’s care? Select four (4) from the following list:

Barry McKenzie, a 48-year-old Anangu man, presents to your remote clinic with worsening right foot pain, swelling, and foul-smelling discharge for the past week. He has type 2 diabetes and reports he stubbed his toe two weeks ago but didn’t seek care. He walks with a limp and says he has not been able to wear shoes due to pain. He lives in a remote outstation with no access to a vehicle and limited refrigeration for medications. His blood glucose levels have been ‘up and down’ and he has not taken any medications in the past month.

Medications: Previously prescribed metformin and gliclazide, but not taken recently

Allergies: Nil known

Past history: T2DM (diagnosed 10 years ago), peripheral neuropathy, CKD stage 2, smoking 20/day

Social history: Lives in a remote community without consistent electricity or transport access, food insecurity, smokes, no alcohol

Examination findings: Afebrile, HR 94 bpm, BP 140/86 mmHg. Right foot swollen, erythematous with malodorous ulcer at base of 2nd toe, exposing tendon. Loss of light touch and vibration sense to mid-calf. Capillary refill 3 seconds. Weak dorsalis pedis pulse. No systemic signs of sepsis

Investigations: BSL 18.7 mmol/L, HbA1c 11.2%, CRP 84 mg/L, WCC 13.4 x10⁹/L, eGFR 58 mL/min. X-ray (remote viewing): soft tissue swelling, no gas or bony involvement seen

What are the most appropriate next steps in Barry’s care? Select four (4) from the following list:

Yvonne Bonner, a 32-year-old Eastern Arrernte woman, presents for a reproductive health consultation at your urban Aboriginal Community Controlled Health Service. She is not currently using contraception and is considering pregnancy with her new partner. She previously had a miscarriage at 10 weeks and was diagnosed with gestational diabetes in a prior pregnancy. Yvonne smokes and drinks occasionally and has a BMI of 34. She expresses concerns about her health and the risks of pregnancy complications.

Medications: Nil

Allergies: Nil known

Past history: GDM, miscarriage, obesity

Social history: Lives with partner and two children from a previous relationship. Stable housing. Smokes 5/day, drinks alcohol on weekends (approx. 3–4 standard drinks). Some food insecurity. Family support available

Examination findings: BP 132/88 mmHg, HR 84 bpm, BMI 34, non-focal exam

Investigations: HbA1c 6.1%, ferritin 24 µg/L, STI screen negative, cervical screening up to date

What are the most appropriate preconception care actions? Select four (4) from the following list:

Alfie Nangala, a 10-year-old Pintupi boy, presents to your remote clinic with his aunt. She reports he has had a persistent sore throat, low-grade fever, and fatigue for the past 4 days. On review of his history, you note Alfie has had 3 previous presentations in the past year for sore throats, one of which was associated with a positive rapid strep test. He was treated with antibiotics each time, but follow-up has been inconsistent. The community has a high prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD).

Medications: Nil

Allergies: Nil known

Past history: Multiple sore throats, no known heart disease, no previous echocardiogram

Social history: Lives with extended family in overcrowded housing. Attends school irregularly. Has not previously engaged with routine preventative health assessments

Examination findings: T 37.8°C, HR 98 bpm, BP 108/66 mmHg. Mild tonsillar erythema without exudate, no cervical lymphadenopathy. Heart sounds dual with soft systolic murmur best heard at apex. No joint swelling or rash. No hepatosplenomegaly

What are the most appropriate next steps in Alfie’s care? Select four (4) from the following list:

Lorraine Muckan, a 56-year-old Kuku Yalanji woman, presents to your regional general practice with ongoing fatigue, low mood, and poor appetite. She reports experiencing ‘lots of grief and stress’ in recent years following the deaths of her siblings and separation from her partner. Lorraine also mentions significant weight loss, poor sleep, and general body aches. She has a long-standing history of type 2 diabetes and hypertension but has not attended the clinic for 18 months.

Medications: Irbesartan (non-compliant), previously on metformin (ceased herself)

Allergies: Nil known

Past history: T2DM, hypertension, grief and trauma history, smoker

Social history: Lives alone in government housing, limited family contact, receives disability support pension. Reports she ‘doesn’t feel like leaving the house’

Examination findings: Appears withdrawn, weight 52 kg (BMI 19), BP 138/86 mmHg, HR 74 bpm, flat affect, poor eye contact. No focal neurological signs or suicidality

Investigations: HbA1c 9.5%, eGFR 62, UACR 3.6 mg/mmol, TSH and B12 normal, CRP mildly elevated

What are the most appropriate next steps in Lorraine’s care? Select four (4) from the following list:

Isaiah Briscoe, a 3-year-old Wangkangurru boy, is brought to your remote Aboriginal Health Service by his grandmother due to ongoing coughing and poor weight gain. She reports that Isaiah has had a ‘wet cough’ nearly every day for the past 3 months. He was treated with antibiotics twice for ‘chest infections’, but the cough always returns. He is otherwise active but has occasional wheeze and tires easily when playing. His immunisations are up to date, and he lives with 8 other family members in a small home.

Medications: Nil

Allergies: Nil known

Past history: Multiple lower respiratory tract infections, mild eczema, no previous hospital admissions

Social history: Overcrowded housing, non-smoking household, attends daycare irregularly, access to clean water limited

Examination findings: Mildly underweight, afebrile, RR 28/min, SpO₂ 96% RA. Wet-sounding cough on auscultation, bibasal crackles and wheeze. No clubbing. No hepatosplenomegaly

What are the most appropriate next steps in Isaiah’s care? Select four (4) from the following list:

Carolyn Gumbaynggirr, a 41-year-old Aboriginal woman, presents to your urban Aboriginal Medical Service with worsening pelvic pain and heavy, irregular vaginal bleeding over the past 6 months. She reports flooding-type bleeding lasting 7–10 days, fatigue, and occasional dizziness. Carolyn has not had a cervical screening test in over 10 years and has not had a Pap smear since giving birth to her youngest child 12 years ago. She has had limited contact with healthcare providers due to past negative experiences.

Medications: Nil

Allergies: Nil known

Past history: Four vaginal births, no known chronic illness

Social history: Lives with adult children and grandchildren, helps with caregiving. No tobacco, occasional alcohol. Reports anxiety about medical procedures and ‘feeling shamed’ about discussing women’s health

Examination findings: Pale conjunctivae. Abdomen soft, non-tender. Bimanual examination declined. Speculum deferred due to discomfort. No visible bleeding at time of visit

Investigations: Hb 86 g/L (115–160), MCV 76 fL, Ferritin 10 µg/L, Pregnancy test negative

What are the most appropriate next steps in Carolyn’s care? Select four (4) from the following list:

Trevor Yunupingu, a 62-year-old Yolŋu man, presents to your remote health clinic for routine review. He has a long history of smoking and has become increasingly breathless over the past 12 months, especially when walking to the shop. He reports a daily morning cough with sputum and occasional wheeze. He has not had spirometry previously. He was hospitalised last wet season with ‘a chest infection’ requiring oxygen. He continues to smoke 15 cigarettes a day.

Medications: Nil

Allergies: Nil known

Past history: Chronic productive cough, smoking history 50 pack-years

Social history: Lives in overcrowded housing with limited access to refrigeration. No car. Smokes tobacco only. Supports young grandchildren.

Examination findings: SpO₂ 93% on room air, RR 20/min, chest hyper-resonant with prolonged expiratory phase and scattered wheeze. No cyanosis or peripheral oedema. BMI 22

Investigations: FBC normal. Spirometry: FEV1/FVC ratio 0.58, FEV1 54% predicted. Post-bronchodilator no significant reversibility. CXR: hyperinflation, no focal consolidation

What are the most appropriate next steps in Trevor’s care? Select four (4) from the following list:

Michelle Wirrpanda, a 19-year-old Noongar woman, presents to your rural general practice for follow-up after testing positive for chlamydia on an opportunistic STI screen. She is asymptomatic and not currently using any contraception. Michelle is not in a long-term relationship and says she ‘wasn’t really expecting to get a call’ about the result. She is worried about confidentiality and ‘everyone finding out’.

Medications: Nil

Allergies: Nil known

Past history: Nil chronic conditions, never been pregnant

Social history: Lives with extended family, recently finished school, works part-time in retail. Limited access to transport. Previously hesitant about cervical screening and contraception discussions.

Examination findings: Not performed — patient declined internal examination

Investigations: STI screen: Chlamydia trachomatis positive (NAAT). HIV, syphilis, and hepatitis B negative. Urine pregnancy test negative

What are the most appropriate next steps in Michelle’s care? Select four (4) from the following list:

David Namatjira, a 68-year-old Arrernte man, presents to your urban ACCHS for review of recent blood test results. He has no symptoms but was found to have persistently elevated liver enzymes during routine chronic disease screening. He drinks alcohol occasionally and smoked for many years but quit five years ago. He has a brother who died from liver cancer. David feels well and denies abdominal pain, jaundice, or weight loss.

Medications: Atorvastatin 20 mg daily, metformin 500 mg BD

Allergies: Nil known

Past history: Type 2 diabetes, dyslipidaemia, previously treated hepatitis B infection (childhood exposure)

Social history: Retired, lives with wife, involved in community activities. No current substance use. Access to regular GP care through ACCHS

Examination findings: Weight stable, BMI 29, no hepatosplenomegaly or stigmata of chronic liver disease. BP 132/76 mmHg

Investigations:
ALT 88 U/L (5–40), AST 74 U/L (5–40), GGT 102 U/L (10–60)
HbA1c 7.2%, Ferritin 470 µg/L (30–300), Hepatitis B surface antigen: negative, core antibody: positive
Ultrasound: Mildly increased echogenicity consistent with hepatic steatosis. No focal lesion

What are the most appropriate next steps in David’s care? Select four (4) from the following list:

Kylie Doolan, a 24-year-old Barkindji woman, presents to your urban general practice for follow-up after recently relocating from a regional town. She is 16 weeks pregnant with her first child. Kylie reports nausea has improved but she still feels tired. She is unsure of what antenatal tests she has had. She is not taking any supplements and smokes 8 cigarettes a day. She wants to have her baby at the local hospital but is anxious about ‘being judged’ and hasn’t yet booked in for maternity care.

Medications: Nil

Allergies: Nil known

Past history: Nil significant medical or surgical history

Social history: Lives with partner in rented accommodation, recently moved for partner’s job. No car. No regular GP previously. Some food insecurity and limited local support network

Examination findings: BP 110/70 mmHg, HR 86 bpm, weight 68 kg (BMI 26), no oedema. Appears well, mild pallor. Fundal height appropriate for gestation

Investigations: Hb 102 g/L (115–160), MCV 72 fL, Ferritin 14 µg/L. First trimester screening and serology not available. Ultrasound confirms viable singleton pregnancy at 16 weeks

What are the most appropriate next steps in Kylie’s care? Select four (4) from the following list:

Charlie Yow Yeh, a 51-year-old Torres Strait Islander man, presents to your outer-regional clinic for follow-up of his cardiovascular risk assessment. He has no current symptoms but is concerned about ‘dropping dead like my uncle’. He has a strong family history of premature coronary artery disease. He smokes 10 cigarettes/day and has not previously engaged with preventive healthcare. Charlie works as a council maintenance worker and is often away on country for days at a time. He is not taking any medications and has never had a heart health check.

Medications: Nil

Allergies: Nil known

Past history: Nil known chronic disease

Social history: Lives with partner, supports grandchildren, no regular GP. Diet is high in processed foods, occasional alcohol use, physically active through work

Examination findings: BP 144/92 mmHg, BMI 31, waist circumference 104 cm. Heart sounds dual, no murmurs, peripheral pulses present. No oedema

Investigations: Fasting lipids: TC 6.1 mmol/L, LDL 3.9, HDL 0.9, Trig 2.6
Fasting glucose: 6.3 mmol/L
eGFR 75 mL/min
ECG: Normal sinus rhythm

What are the most appropriate next steps in Charlie’s care? Select four (4) from the following list:

Roseanna Laurie, a 36-year-old Wongatha woman, presents to your regional Aboriginal Medical Service seeking help for poor sleep and ongoing stress. She is caring for her three children and two nephews after her sister was incarcerated. Roseanna reports broken sleep, feeling ‘on edge all the time’, and occasional panic attacks. She drinks alcohol most nights to help her sleep. She is not taking any medications and has never seen a psychologist. She says, ‘I don’t want to go crazy or be judged’.

Medications: Nil

Allergies: Nil known

Past history: Nil formal mental health diagnoses, three previous pregnancies, no history of trauma noted in medical record

Social history: Sole carer for five children, lives in public housing, financial stress, limited transport. Occasionally smokes cannabis. No physical violence disclosed

Examination findings: Appears anxious but cooperative. Vitals within normal limits. No thought disorder or suicidality. Tearful at times during consult

Investigations: Not yet performed

What are the most appropriate next steps in Roseanna’s care? Select four (4) from the following list:

Henry Jabanangka, a 7-year-old Warlpiri boy, is brought to your remote community clinic by his mother due to persistent itch and poor sleep. She reports that Henry has been scratching for weeks and now has sores all over his arms and legs. The household is overcrowded with 12 people living in a small home, and multiple children in the house are affected. She has tried using moisturisers and stopping soap but with no improvement.

Medications: Nil

Allergies: Nil known

Past history: Mild eczema, previous skin infections

Social history: Overcrowded housing, limited access to hot water, inconsistent access to washing machines, attends school irregularly

Examination findings: Afebrile. Generalised excoriated papules with crusting and signs of secondary infection. Lesions most prominent on wrists, axillae, groin and interdigital spaces. Impetigo lesions noted on both legs

Investigations: Not performed

What are the most appropriate next steps in Henry’s care? Select four (4) from the following list:

Malcolm Dhu, a 58-year-old Yamatji man, presents to your outer-regional general practice with worsening fatigue, polydipsia, and weight loss over the past three months. He has not attended a clinic in years and has no previous diagnosis of chronic disease. He is concerned because his father ‘lost his leg to sugar’ and his brother is on dialysis. Malcolm works as a truck driver and is on the road much of the time. He drinks 2–3 cans of soft drink per day and smokes 20 cigarettes/day.

Medications: Nil

Allergies: Nil known

Past history: Nil known

Social history: Lives alone, supports extended family financially, irregular meals, rarely exercises, eats primarily from roadhouses

Examination findings: BP 158/94 mmHg, HR 88 bpm, BMI 32, central obesity, dry oral mucosa, acanthosis nigricans noted at neck

Investigations:
Random BSL: 18.6 mmol/L
HbA1c: 12.3%
Urine ACR: 14.8 mg/mmol (normal <2.5)
eGFR: 62 mL/min/1.73m²

What are the most appropriate next steps in Malcolm’s care? Select four (4) from the following list:

Leah Mununggurr, a 17-year-old Yolŋu woman, presents to your regional Aboriginal Medical Service for contraception advice. She is sexually active with a new partner and does not want to get pregnant. Leah has not used any contraception before and is unsure what her options are. She has not had a cervical screening test. She reports irregular periods and some acne. Leah lives with her extended family and says she doesn’t want ‘anyone to know’ she’s come to the clinic.

Medications: Nil

Allergies: Nil known

Past history: Nil significant medical history

Social history: Lives with family, currently not attending school, no alcohol or smoking, minimal contact with healthcare services in the past

Examination findings: BMI 27, BP 110/70 mmHg, no hirsutism or signs of androgen excess. Appears well and engaged during consultation

Investigations: Not yet performed. Pregnancy test negative. STI screen offered and accepted

What are the most appropriate next steps in Leah’s care? Select four (4) from the following list:

Peter Warlimpirrnga, a 72-year-old Pintupi man, presents to your remote community clinic for review of chronic back pain. He has been taking over-the-counter medications and bush medicine but reports worsening stiffness, sleep disturbance, and difficulty walking. He lives in a small community 300 km from the nearest hospital and often misses appointments due to lack of transport. Peter speaks limited English and prefers communication in Pintupi–Luritja through an interpreter or Aboriginal Health Worker.

Medications: Occasional paracetamol and bush balm

Allergies: Nil known

Past history: Osteoarthritis (self-reported), longstanding smoking, no known chronic disease diagnoses

Social history: Lives with family in overcrowded housing, no car, culturally connected, prefers traditional healing methods where possible

Examination findings: BMI 20, stooped posture, reduced lumbar flexion, tenderness over lower spine, no neurological deficits. BP 132/80, HR 78. No signs of systemic illness

Investigations: Basic bloods and imaging not available onsite. Prior plain X-ray (1 year ago) showed degenerative changes consistent with osteoarthritis

What are the most appropriate next steps in Peter’s care? Select four (4) from the following list:

Samantha Watego, a 43-year-old Bundjalung woman, presents to your metropolitan ACCHS for a preventative health check. She feels well and has no current medical complaints but says, ‘I just want to stay healthy for my kids’. She hasn’t been to a doctor in years. Samantha’s mother died from breast cancer at age 49, and her older sister is currently undergoing treatment for bowel cancer. Samantha works part-time, has two teenage children, and occasionally smokes and drinks socially. She has never had a mammogram or bowel screening test.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with children, no transport issues, culturally connected. Occasional alcohol and tobacco use. No regular GP prior to this visit

Examination findings: BP 126/80, BMI 27, non-focal examination

Investigations: Point-of-care HbA1c 5.8%, total cholesterol 4.3 mmol/L, eGFR 84

What are the most appropriate next steps in Samantha’s care? Select four (4) from the following list:

Aaron Djambatj, a 29-year-old Yolŋu man, presents to your remote clinic with a three-week history of fatigue, low-grade fevers, and a painful right knee. He reports intermittent swelling in the knee and occasional shortness of breath. He had a ‘sore throat’ about a month ago which resolved without treatment. He has a history of untreated skin sores in childhood and was hospitalised once at age 12 for a joint infection. Aaron lives in a remote community and hasn’t seen a doctor in years.

Medications: Nil

Allergies: Nil known

Past history: Recurrent skin infections, no known heart disease

Social history: Lives with extended family, overcrowded housing, no access to private vehicle, high rates of ARF in community

Examination findings: Temp 38.1°C, HR 104 bpm, BP 124/76 mmHg, pansystolic murmur loudest at apex, swollen tender right knee with limited range of motion. No rash or chorea

Investigations: CRP 75 mg/L, WCC 12.8 x10⁹/L, ASOT positive, ESR 52 mm/hr, ECG: sinus tachycardia, PR interval normal

What are the most appropriate next steps in Aaron’s care? Select four (4) from the following list:

Shania Freeman, a 15-year-old Torres Strait Islander girl, presents with her mother to your regional general practice clinic for a routine check-up. Shania has no acute symptoms but her mother is concerned about tiredness, poor school concentration, and her daughter ‘not eating properly’. They recently moved from a remote community. Shania has never had a health check and does not recall any vaccinations since primary school. She has started menstruating, with irregular heavy periods. She is otherwise well and not sexually active.

Medications: Nil

Allergies: Nil known

Past history: Nil documented, never hospitalised

Social history: Lives with mother and younger siblings, now in public housing. No regular GP, receives Centrelink Youth Allowance. Attends school irregularly

Examination findings: BMI 19, pale conjunctivae, BP 108/64 mmHg, no lymphadenopathy or hepatosplenomegaly. Normal heart and lung sounds

Investigations: Hb 92 g/L (115–160), MCV 72 fL (80–96), Ferritin 8 µg/L (15–200), CRP normal, beta-HCG negative

What are the most appropriate next steps in Shania’s care? Select four (4) from the following list:

Wally Tjapaltjarri, a 64-year-old Pintupi man, presents to your remote clinic with progressive vision loss in both eyes over the past year. He describes it as ‘getting cloudy’ and says he’s having trouble reading and recognising people. He hasn’t had an eye check in many years and doesn’t wear glasses. Wally has type 2 diabetes diagnosed 8 years ago but rarely attends reviews and is not currently taking any medications. He speaks limited English and prefers a male Aboriginal Health Worker to assist in communication.

Medications: Nil

Allergies: Nil known

Past history: T2DM (poorly controlled), hypertension (diagnosed but untreated), ex-smoker

Social history: Lives in a remote community, reliant on community transport, no phone, culturally connected elder

Examination findings: Visual acuity: R 6/36, L 6/60 (uncorrected), BP 146/88 mmHg, capillary glucose 15.4 mmol/L. No acute neurological signs. Fundoscopy not possible in clinic

Investigations: HbA1c 10.2%, eGFR 60 mL/min, urine ACR 8.4 mg/mmol

What are the most appropriate next steps in Wally’s care? Select four (4) from the following list:

Maree Kulumburu, a 34-year-old Gija woman, presents to your remote health clinic with ongoing fatigue and increasing shortness of breath over the past few months. She has had multiple hospital admissions in the past two years for ‘chest infections’ and is known to have bronchiectasis diagnosed by CT in Darwin three years ago. She has not had follow-up since and struggles with regular medication due to access issues. She smokes 15 cigarettes per day. There is no history of asthma or cardiac disease.

Medications: Salbutamol PRN, doxycycline (taken intermittently for chest infections)

Allergies: Nil known

Past history: Bronchiectasis, multiple lower respiratory tract infections, childhood pneumonia

Social history: Lives in overcrowded housing, no regular fridge, difficulty attending clinics due to caregiving responsibilities

Examination findings: RR 22/min, SpO₂ 92% RA, coarse inspiratory crackles bilaterally, no wheeze. Heart sounds normal. BMI 22

Investigations: Sputum culture pending, last CRP 32 mg/L, CXR: bronchial wall thickening consistent with known bronchiectasis. No consolidation

What are the most appropriate next steps in Maree’s care? Select four (4) from the following list:

Jasmine Yarran, a 28-year-old Noongar woman, presents to your inner-city Aboriginal Medical Service for review following a positive urine pregnancy test. She is approximately 6 weeks pregnant by dates. This is her third pregnancy; she had one previous miscarriage and one preterm birth at 33 weeks. She expresses excitement but also concern, stating she wants ‘to do everything right this time’. Jasmine has experienced previous trauma in healthcare settings and prefers to be seen by female practitioners. She smokes 10 cigarettes per day and is unsure about what antenatal care she needs.

Medications: Nil

Allergies: Nil known

Past history: Miscarriage (at 8 weeks), preterm delivery (no cause identified), low vitamin D, intermittent anxiety

Social history: Lives in supported accommodation, no regular partner, occasional alcohol (ceased when she found out about pregnancy), no family nearby, limited income

Examination findings: Appears well, BP 112/70 mmHg, HR 82 bpm, BMI 26

Investigations: Not yet performed

What are the most appropriate next steps in Jasmine’s care? Select four (4) from the following list:

Colin Mamarika, a 49-year-old Anindilyakwa man, presents to your regional general practice with increasing pain and swelling in his right great toe. He says it’s been coming and going for the last few months but is now worse and affecting his ability to work. He works in construction and spends a lot of time on his feet. Colin drinks beer most evenings and eats a high meat diet. He has not had regular healthcare for several years and has not been diagnosed with any chronic disease.

Medications: Nil

Allergies: Nil known

Past history: Nil known chronic conditions

Social history: Lives with partner and grandchildren. Drinks daily (3–4 beers), no tobacco. Limited access to transport. No previous engagement with chronic disease screening

Examination findings: Right first MTP joint is swollen, erythematous, and tender to touch. Warm but no overlying skin breaks. Vitals normal. No systemic symptoms

Investigations: UEC: Creatinine 97 µmol/L, eGFR 81. CRP 28 mg/L, uric acid 0.52 mmol/L (high). X-ray (if available) shows soft tissue swelling without erosions

What are the most appropriate next steps in Colin’s care? Select four (4) from the following list:

Aaliyah Doolan, a 6-month-old Yorta Yorta girl, is brought to your Aboriginal Medical Service by her grandmother for immunisations. The grandmother is concerned because Aaliyah has had a persistent cough for 3 weeks, especially at night. She was born at term with no complications. She has not yet received her 6-month vaccinations. The family has recently moved between housing and missed several appointments. There are four other young children in the household, and two recently had colds. Aaliyah is feeding well but has not gained much weight since her 4-month check.

Medications: Nil

Allergies: Nil known

Past history: Immunisations up to 4 months, normal development

Social history: Lives with extended family in public housing, housing instability, food insecurity, non-smoking household

Examination findings: Afebrile, RR 34, SpO₂ 97% RA, scattered crackles and wet cough audible. Weight is below 10th percentile for age. No chest wall indrawing

What are the most appropriate next steps in Aaliyah’s care? Select four (4) from the following list:

Norma Karpany, a 61-year-old Narungga woman, presents to your urban general practice clinic with ongoing sadness, fatigue, and loss of interest in her usual community activities. She reports feeling increasingly isolated after her partner died last year and says she is ‘just going through the motions’. She’s sleeping poorly, has little appetite, and worries she’s becoming a burden to her family. Norma has a past history of type 2 diabetes and is on oral hypoglycaemics. She has never received formal mental health care.

Medications: Metformin 1g BD, gliclazide MR 60 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, osteoarthritis

Social history: Lives alone, receives a carer’s pension, identifies strongly with community and cultural identity. Limited mobility due to knee pain. Occasional alcohol. No smoking

Examination findings: Appears flat and tearful. BP 138/84 mmHg, HR 76. No suicidal ideation. BMI 30. PHQ-9 score: 18 (moderate–severe)

What are the most appropriate next steps in Norma’s care? Select four (4) from the following list:

Isaac Riley, a 40-year-old Palawa man, presents to your regional general practice clinic requesting help to stop drinking. He reports drinking a six-pack of beer daily for many years, which has recently increased after losing his job. He feels tired, has poor sleep, and has missed family obligations due to his drinking. Isaac says he’s tried to stop on his own but experiences shakes, sweating, and insomnia if he doesn’t drink for more than a day. He is worried about losing connection to his children if this continues.

Medications: Nil

Allergies: Nil known

Past history: Nil known medical conditions

Social history: Lives alone, culturally connected, limited income, no transport, strong desire to re-engage with family and community

Examination findings: BP 132/78, HR 88 bpm, no signs of jaundice or hepatomegaly. Appears anxious. No clinical signs of Wernicke’s encephalopathy. CIWA-Ar score 9 (mild withdrawal)

Investigations: LFTs: GGT 144 U/L (10–55), ALT 68 U/L (5–40), AST 74 U/L (5–40). MCV 104 fL. Blood glucose and renal function normal

What are the most appropriate next steps in Isaac’s care? Select four (4) from the following list:

Melinda Geia, a 25-year-old Kuku Yalanji woman, presents to your urban Aboriginal Medical Service with a persistent vaginal discharge. She reports it has been present for 3 weeks and is associated with mild itch and odour, but no pelvic pain or bleeding. She is sexually active with one regular male partner and is not using any contraception. She has not had a cervical screening test and last had STI screening over a year ago. Melinda is concerned about privacy and doesn’t want to be examined.

Medications: Nil

Allergies: Nil known

Past history: Nil significant medical history

Social history: Lives with partner and extended family, works part-time, culturally connected, expresses shame around women’s health issues

Examination findings: Not performed (declined). Appears well. No fever, abdominal pain, or systemic symptoms

Investigations: Self-collected vaginal swab: Trichomonas vaginalis positive, Chlamydia and Gonorrhoea negative. Pregnancy test negative

What are the most appropriate next steps in Melinda’s care? Select four (4) from the following list:

Ronny Walmbaar, a 57-year-old Wik man, presents to your remote health clinic with a wound on his right foot that has not healed for over three weeks. He says he ‘stood on something’ while walking barefoot, and the wound became red and swollen a few days later. He thought it was getting better but now has a foul-smelling discharge. Ronny has had type 2 diabetes for over 10 years and smokes 20 cigarettes a day. He has not had regular foot checks and has poor access to podiatry services in his community.

Medications: Metformin 1g BD, gliclazide MR 60 mg daily, ramipril 5 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, previous hospitalisation for skin infection

Social history: Lives in overcrowded housing, relies on community transport, no regular footwear, culturally connected and engaged in community roles

Examination findings: Temp 37.9°C, HR 92 bpm, BP 134/78 mmHg. Ulcer on plantar surface of right forefoot, 2.5 cm in diameter, purulent discharge, surrounding erythema, decreased peripheral sensation and weak dorsalis pedis pulse

Investigations: BSL 16.8 mmol/L, HbA1c 9.6%, CRP 58 mg/L, WCC 13.2 x10⁹/L, X-ray foot: no osteomyelitis evident

What are the most appropriate next steps in Ronny’s care? Select four (4) from the following list:

Tyson Nangala, a 12-year-old Warlpiri boy, is brought to your remote community clinic by his aunt with concerns about bedwetting. He has been wetting the bed most nights since early childhood and is now being teased by other children. Tyson is otherwise healthy and doing well at school. There is no history of daytime incontinence, urgency, or urinary tract infections. His aunt says the family doesn’t talk about health problems much and Tyson has never seen a doctor for this before.

Medications: Nil

Allergies: Nil known

Past history: Normal birth and development, no surgeries or chronic illness

Social history: Lives with extended family in overcrowded housing, limited access to washing facilities, culturally strong household

Examination findings: Normal growth and development. Abdomen soft, non-tender. Neurological exam normal. No signs of constipation. BP 100/64 mmHg

Investigations: Urinalysis: normal. No glucose, protein or infection. First-morning urine osmolality pending

What are the most appropriate next steps in Tyson’s care? Select four (4) from the following list:

Grace Ngalakan, a 35-year-old Rembarrnga woman, presents to your regional Aboriginal Medical Service for review of persistent tiredness and low mood. She has also noticed increased facial hair and irregular menstrual cycles over the past year. She is not currently trying to conceive but expresses concern that she may be ‘barramundi dreaming’ (infertile). Grace has never had a formal diagnosis but says ‘this has been going on for years’. She has struggled with weight since adolescence.

Medications: Nil

Allergies: Nil known

Past history: Nil diagnosed medical conditions, no pregnancies

Social history: Lives with extended family, unemployed, high food insecurity, occasional alcohol, no tobacco use. Reports feeling ‘shamed’ talking about women’s health issues

Examination findings: BMI 34, BP 126/82 mmHg, Ferriman-Gallwey score 10, acanthosis nigricans on neck. No goitre or galactorrhoea

Investigations: HbA1c 6.2%, fasting insulin elevated, testosterone mildly elevated, LH:FSH ratio 3:1. Pelvic ultrasound: multiple small peripheral ovarian follicles bilaterally

What are the most appropriate next steps in Grace’s care? Select four (4) from the following list:

Darryn Oakley, a 46-year-old Wiradjuri man, presents to your rural clinic with persistent heartburn and regurgitation, especially at night. He reports a burning sensation in his chest after meals, worsened by lying down. He has been taking over-the-counter antacids for several months with minimal relief. Darryn drinks alcohol most evenings and smokes a pack of cigarettes daily. He has not seen a doctor for several years. His father died of oesophageal cancer at 58.

Medications: Nil

Allergies: Nil known

Past history: Nil documented, no prior investigations

Social history: Lives with partner and grandchildren, works in local council maintenance. High alcohol and tobacco use, inconsistent diet due to shift work

Examination findings: BMI 31, BP 138/86 mmHg, normal heart and respiratory examination. Abdomen soft, no tenderness or organomegaly

Investigations: FBC: Hb 122 g/L, MCV 83 fL. H. pylori test pending. No prior endoscopy

What are the most appropriate next steps in Darryn’s care? Select four (4) from the following list:

Theresa Wirrpanda, a 19-year-old Noongar woman, presents to your metropolitan Aboriginal Medical Service requesting a contraceptive implant. She recently became sexually active and says she doesn’t want to ‘get stuck like my cousin did’. Theresa has never had a cervical screening test or STI check and has no significant medical history. She is shy and initially reluctant to speak openly about sexual health. She lives with her mother and younger siblings, attends TAFE, and helps with childcare at home.

Medications: Nil

Allergies: Nil known

Past history: Nil medical or surgical history

Social history: Lives in multigenerational household, close-knit community, no current partner. No smoking or alcohol use

Examination findings: Declines pelvic examination. Vitals within normal limits. Appears well, BMI 23

Investigations: Not yet performed. Urine pregnancy test negative

What are the most appropriate next steps in Theresa’s care? Select four (4) from the following list:

Clinton Mookarai, a 52-year-old Kija man, presents to your regional GP clinic for follow-up after a recent hospital admission for pneumonia. During admission, he was found to have bilateral basal crackles and persistent cough. A CT chest performed showed early bronchiectasis. Clinton has had multiple episodes of ‘chest infections’ over the past five years, often treated with antibiotics but with minimal follow-up. He is now back in community and wishes to avoid hospital again. He continues to smoke 15 cigarettes per day.

Medications: Salbutamol inhaler PRN

Allergies: Nil known

Past history: Multiple lower respiratory tract infections, pneumonia x2 in past 3 years, chronic productive cough

Social history: Lives in remote community, no regular transport, limited access to running water, has family support

Examination findings: RR 20, SpO₂ 95% RA, persistent wet cough, coarse crackles at both bases. No wheeze, cardiovascular exam normal

Investigations: CRP 18 mg/L, sputum culture pending, previous CT chest shows cylindrical bronchiectasis in lower lobes

What are the most appropriate next steps in Clinton’s care? Select four (4) from the following list:

Rachel Gundagai, a 31-year-old Wiradjuri woman, presents to your urban Aboriginal Medical Service with ongoing pelvic pain and heavy menstrual bleeding. She describes cramping that lasts for several days before and during her period, with clots and flooding that affects her ability to work. She has not had a cervical screening test and reports fear and discomfort during previous health checks. Rachel has no children and is not currently trying to conceive. She takes paracetamol for pain, which provides little relief.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Menstrual irregularity since adolescence, no surgeries, not sexually active currently

Social history: Lives with mother, works in retail, culturally connected, reports past trauma during childhood. No smoking or alcohol

Examination findings: Declined pelvic exam. Appears tired but otherwise well. Abdomen soft, mild suprapubic tenderness

Investigations: FBC: Hb 98 g/L (115–160), MCV 78 fL (80–96), Ferritin 12 µg/L (15–200). Pelvic ultrasound pending

What are the most appropriate next steps in Rachel’s care? Select four (4) from the following list:

Jarrad Walbunga, a 68-year-old Yuin man, presents to your regional general practice clinic for review of longstanding type 2 diabetes. He reports numbness in his feet and occasional imbalance. He lives alone and has recently had a fall at home, which he attributes to ‘old age’. Jarrad has been taking metformin and gliclazide for many years but rarely checks his blood sugar levels. He has not had recent diabetes screening or foot checks and says, ‘I only come to the doctor when I really have to’.

Medications: Metformin 1 g BD, Gliclazide MR 60 mg daily

Allergies: Nil known

Past history: T2DM (diagnosed 15 years ago), hypertension, cataracts (surgery 2 years ago)

Social history: Lives in social housing, widower, smokes 10 cigarettes/day, limited support, infrequent health visits, culturally connected Elder

Examination findings: BP 144/82 mmHg, BMI 26, diminished vibration and monofilament sensation in both feet, intact pulses. Gait unsteady

Investigations: HbA1c 8.2%, eGFR 68, urine ACR 6.1 mg/mmol, lipids borderline

What are the most appropriate next steps in Jarrad’s care? Select four (4) from the following list:

Amelia Bani, a 24-year-old Torres Strait Islander woman, presents to your remote clinic with a dry cough and low-grade fever for the past 3 weeks. She has night sweats and says she’s lost some weight, but didn’t think much of it. Amelia lives with four other family members, including a cousin recently released from prison. She is not a smoker, has no previous lung disease, and works at the local store. She has never had a chest X-ray or screening for tuberculosis (TB).

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives in overcrowded housing, occasional alcohol use, Torres Strait Islander, no recent travel overseas

Examination findings: T 37.8°C, HR 94 bpm, RR 20, SpO₂ 96% RA. Chest clear, no lymphadenopathy. Appears tired but not acutely unwell

Investigations: CXR: right upper lobe infiltrate with cavitation. Sputum AFB positive (Ziehl-Neelsen stain), GeneXpert pending

What are the most appropriate next steps in Amelia’s care? Select four (4) from the following list:

Lisa Djarla, a 37-year-old Pitjantjatjara woman, presents to your regional general practice with severe left-sided ear pain and discharge for the past 4 days. She reports some hearing loss and has been having ‘sore ears on and off for years’. Lisa recalls several courses of antibiotics in childhood and a perforated eardrum. She works in early childhood education and finds it hard to hear the children. She smokes and lives in a crowded household with four young nieces and nephews who often have runny noses and coughs.

Medications: Nil

Allergies: Nil known

Past history: Recurrent otitis media, suspected chronic suppurative otitis media (CSOM), no prior ear surgery

Social history: Lives in overcrowded housing, no regular access to audiology or ENT services, culturally strong community role model

Examination findings: Otoscopy: Left ear with mucopurulent discharge, large central perforation, inflamed canal. Right ear intact but dull. Hearing appears reduced on L side. No mastoid tenderness

Investigations: Audiometry pending. No systemic signs of infection. Temp 37.3°C

What are the most appropriate next steps in Lisa’s care? Select four (4) from the following list:

Dean Warragul, a 59-year-old Ngarrindjeri man, presents to your general practice clinic for review of persistent fatigue and poor concentration. He has a long-standing history of hypertension and recently relocated from a remote community to be closer to family. Dean reports falling asleep during the day, loud snoring (reported by his daughter), and waking unrefreshed. He has noticed a gradual increase in weight over the years and feels increasingly socially withdrawn.

Medications: Amlodipine 10 mg daily, perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, overweight

Social history: Lives with daughter and grandchildren, previously lived remotely, ex-smoker, no alcohol. Centrelink recipient

Examination findings: BP 138/84 mmHg, BMI 35, neck circumference 45 cm, crowded oropharynx, no goitre. Epworth Sleepiness Score: 15/24

Investigations: HbA1c 6.4%, eGFR 74, cholesterol mildly elevated. No previous sleep study

What are the most appropriate next steps in Dean’s care? Select four (4) from the following list:

Kylie Moorditj, a 45-year-old Noongar woman, presents to your Aboriginal Medical Service with concerns about persistent abdominal bloating and altered bowel habits for the past 3 months. She reports increased constipation alternating with loose stools, and a sensation of incomplete emptying. Kylie has no rectal bleeding or weight loss but feels increasingly tired and anxious about her symptoms. She has not had bowel cancer screening and her mother died from colorectal cancer at age 52.

Medications: Nil

Allergies: Nil known

Past history: Anxiety (mild), iron deficiency 2 years ago

Social history: Lives with partner and children, works in admin, no smoking or alcohol, limited engagement with preventive healthcare, feels ‘shame’ about bowel symptoms

Examination findings: BMI 29, soft non-tender abdomen, no masses, bowel sounds normal

Investigations: FBC pending. No recent iFOBT or colonoscopy

What are the most appropriate next steps in Kylie’s care? Select four (4) from the following list:

Tommy Barunga, a 5-year-old Yolŋu boy, is brought to your remote health clinic by his grandmother with concerns about frequent ‘snotty nose’, cough, and poor school attendance. His grandmother says Tommy has had more than six colds in the last few months and often wakes at night coughing. He’s been given antibiotics several times but ‘it just keeps coming back’. There is no history of wheeze, but he does snore at night. His growth and development have been normal to date.

Medications: Nil

Allergies: Nil known

Past history: Recurrent upper respiratory tract infections, tympanostomy tubes at age 2 (no longer in place)

Social history: Lives in overcrowded housing with 9 family members. Household includes smokers. No previous ENT referral

Examination findings: Afebrile. Mild nasal discharge, mouth breathing, tonsillar hypertrophy, bilateral conductive hearing loss on tuning fork testing. Lungs clear

Investigations: Audiometry: mild bilateral conductive hearing loss. No previous hearing assessments documented

What are the most appropriate next steps in Tommy’s care? Select four (4) from the following list:

Leanne Doolan, a 29-year-old Gubbi Gubbi woman, presents to your Aboriginal Medical Service for follow-up of a recent chlamydia diagnosis. She was treated with a single dose of azithromycin 1 g one week ago. She reports no current symptoms but is worried about long-term effects on her fertility. Leanne has had two previous STIs in the past, and has never had a Pap smear or cervical screening test. She is currently in a new relationship and is unsure whether her partner was tested or treated.

Medications: Nil

Allergies: Nil known

Past history: Treated chlamydia x2, nil pregnancies, no chronic conditions

Social history: Lives with partner, casual employment, culturally connected but reports ‘shame’ in discussing sexual health, no regular GP

Examination findings: Declines pelvic exam, appears well, afebrile, no lower abdominal tenderness

Investigations: NAAT confirmed chlamydia infection. Repeat test of cure not yet done

What are the most appropriate next steps in Leanne’s care? Select four (4) from the following list:

Nathan Murrin, a 33-year-old Kalkadoon man, presents to your regional GP clinic with right upper abdominal discomfort, fatigue, and dark urine for the past week. He denies alcohol use, intravenous drug use, or recent overseas travel. He mentions that a cousin was recently diagnosed with hepatitis B. Nathan has not engaged in regular healthcare but recalls being told he had ‘hepatitis as a kid’. He works in construction and lives with his partner and two children.

Medications: Nil

Allergies: Nil known

Past history: Unknown hepatitis diagnosis in childhood, no follow-up

Social history: Lives in regional town, Aboriginal Health Worker known to family, no smoking or alcohol, culturally connected

Examination findings: Mild right upper quadrant tenderness, no hepatomegaly or jaundice. Afebrile. BMI 28

Investigations: LFTs: ALT 165 U/L (5–40), AST 140 U/L (5–40), GGT 45 U/L (10–55), Bilirubin 22 µmol/L (0–20). Hepatitis serology: HBsAg positive, HBeAg negative, anti-HBc IgG positive, anti-HBs negative

What are the most appropriate next steps in Nathan’s care? Select four (4) from the following list: