KFP – Rural health

Peter Thompson, aged 72, presents to your rural general practice with progressive fatigue, shortness of breath on exertion, and swelling in his ankles over the past two months. He reports orthopnoea and occasional nocturnal cough but denies chest pain or palpitations. He lives alone on a cattle property 90 minutes from the nearest hospital. He has found it increasingly difficult to manage the farm due to his symptoms.

Medications: Irbesartan 150 mg daily, Rosuvastatin 10 mg daily, Aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia, myocardial infarction (2018)

Social history: Ex-smoker (40 pack-years, ceased 2019), drinks 2-3 standard drinks daily. No recent travel. No ATSI background.

Examination findings: BP 106/65 mmHg, HR 92 bpm regular, JVP elevated at 4 cm above sternal angle, bibasal crackles, bilateral pitting oedema to mid-calf, S3 gallop

Investigations:

FBC: Hb 128 g/L (130–180), WCC 7.2 x10^9/L (4–11), Platelets 245 x10^9/L (150–400)

U&E: Na 136 mmol/L (135–145), K 4.4 mmol/L (3.5–5.0), Urea 8.6 mmol/L (2.5–7.8), Creatinine 108 µmol/L (60–110)

ECG: Sinus rhythm, Q waves in II, III, aVF

[Insert Image Here]

What is the most appropriate next step in management? Select three (3) from the following list:

Sharon Doolan, a 31-year-old Aboriginal woman, presents to your remote clinic with abdominal pain, bloating, and intermittent diarrhoea for several months. She reports feeling tired and occasionally light-headed. Her appetite has been reduced and she has unintentionally lost 6 kg. There is no vomiting, rectal bleeding, or recent travel. She has not seen a doctor in over two years and has not had any recent blood tests.

Medications: Nil

Allergies: Nil known

Past history: G3P3, gestational diabetes with last pregnancy, mild iron deficiency anaemia 3 years ago

Family history: Her mother has type 2 diabetes and hypothyroidism

Social history: Lives with extended family in a small community. Diet is low in fresh fruit and vegetables. Limited access to transport. Drinks 1–2 standard drinks/week, non-smoker. No recent travel. Reports difficulty accessing fresh food and healthcare locally.

Examination findings: Pale conjunctivae, BMI 18.9 kg/m², mild diffuse abdominal tenderness, no guarding or rebound. No organomegaly. Normal bowel sounds. No peripheral stigmata of chronic liver disease.

Investigations:

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

David Langford, a 64-year-old retired stockman, presents to your rural general practice with a four-week history of progressive hoarseness and occasional mild dysphagia. He denies pain, weight loss or haemoptysis. He is concerned because the symptoms are affecting his ability to sing in the local country music group.

Medications: Nil

Allergies: Nil known

Past history: Gastro-oesophageal reflux, hypertension

Social history: Long-term smoker (45 pack-years), drinks 6–8 standard drinks per day, lives alone 70 km from town. No recent travel. Previously worked on remote stations in the NT and WA.

Examination findings: Mildly husky voice, no lymphadenopathy, oropharynx unremarkable, neck supple, no masses palpable. Respiratory and cardiovascular exams normal.

What are the most appropriate next steps in his management? Select two (2) from the following list:

Marina Koroheke, a 28-year-old Māori woman, presents to your rural clinic in northern NSW with left lower quadrant abdominal pain that has been worsening over the past 24 hours. She also reports nausea, some diarrhoea, and feeling feverish. She is otherwise healthy and has never been pregnant. She reports regular menstrual cycles, with her last period starting 10 days ago. There is no history of recent travel. She is sexually active with a male partner and uses no contraception.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works part-time in a tourist cafe. Lives in shared accommodation. Non-smoker, drinks occasionally. No ATSI background.

Examination findings: T 38.4°C, HR 96 bpm, BP 108/70 mmHg, mild left iliac fossa tenderness without guarding, mild cervical motion tenderness on bimanual examination. No vaginal discharge. No adnexal masses palpated. Bowel sounds normal.

Investigations: Urine pregnancy test: Negative. High vaginal swab collected for NAAT. Urinalysis: No nitrites or leukocytes. Full blood count: WCC 13.5 x10^9/L (4–11), Neutrophils 10.4 x10^9/L

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

Samir Hassan, a 53-year-old refugee from Syria, presents to your remote GP clinic with a three-month history of persistent dry cough, low-grade fevers, night sweats, fatigue, and a 5 kg weight loss. He arrived in Australia nine months ago and lives in a small rural town with limited health infrastructure. He has not had any screening blood tests since arrival. He is a non-smoker and takes no regular medications. He reports no chest pain or haemoptysis. He works part-time at a local abattoir.

Medications: Nil

Allergies: Nil known

Past history: Treated for latent tuberculosis (TB) as a teenager, no known diabetes, no history of cancer

Social history: Lives with wife and three children. Language barrier present; you consult with a trained interpreter. Limited access to transport. No ATSI background.

Examination findings: T 37.8°C, RR 18, HR 88 bpm, BP 122/75 mmHg. Mild crackles in the right upper zone. No lymphadenopathy. No clubbing. Weight 62 kg (previously 67 kg). Normal cardiovascular, abdominal and neurological exams.

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

Margie Wallace, a 74-year-old woman from a remote Aboriginal community, is brought to your rural health clinic by her niece. Margie has a long-standing history of poorly controlled type 2 diabetes and hypertension. Over the past two months, her family has noticed increasing confusion, poor appetite, and unsteadiness. She had a fall last week but was not injured. Margie speaks limited English and her niece acts as her informal carer. The community has no permanent doctor or pharmacist, and Margie’s medications are dispensed through a weekly dosing aid prepared by the regional hospital pharmacy.

Medications: Metformin 500 mg bd, Gliclazide MR 60 mg daily, Perindopril 5 mg daily, Amlodipine 5 mg daily, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, hyperlipidaemia, diabetic retinopathy, stage 3 CKD

Social history: Lives in a remote Indigenous community 500 km from the nearest regional hospital. No access to on-site pathology or imaging. Community nurse visits weekly. Smoked until age 65, nil alcohol use.

Examination findings: BP 102/58 mmHg, HR 70 bpm, RR 16, T 36.9°C. Alert but disoriented. Mild unsteadiness on gait testing. Neurological exam otherwise unremarkable. Peripheral pulses present. Mild bilateral pedal oedema. No signs of infection or trauma.

Point-of-care testing:

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

Barry McLeod, a 45-year-old truck driver living in a remote inland Queensland town, presents with chronic lower back pain that has progressively worsened over the past 8 months. He denies any recent trauma, weight loss, or bowel/bladder symptoms. The pain is worse at night and improves with movement. Over-the-counter paracetamol and ibuprofen provide minimal relief. Barry has limited access to local medical services and often works long haul across regional Australia.

Medications: Ibuprofen 400 mg prn

Allergies: Nil known

Past history: Nil significant

Social history: Smokes 10 cigarettes/day. Lives alone in demountable housing. No access to allied health locally. Family in Toowoomba. No recent travel. No ATSI background.

Examination findings: Normal gait. Lumbar flexion limited and painful. No tenderness over vertebrae. Straight leg raise negative bilaterally. Reflexes and sensation intact. Schober’s test shows 3 cm increase. No spinal deformities noted. No signs of systemic illness.

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

Ngarrindjeri woman Irene Kartinyeri, aged 68, presents to your rural Aboriginal Health Service with worsening exertional dyspnoea and productive cough over several months. She has had three exacerbations requiring antibiotics in the past year. She has a 45-pack-year smoking history and quit two years ago. She now walks short distances with frequent rest stops. She feels isolated and reports difficulty getting to town for appointments.

Medications: Salbutamol inhaler prn, ramipril 5 mg daily

Allergies: Nil known

Past history: Hypertension, chronic bronchitis, recurrent chest infections, no known asthma

Social history: Lives alone in a remote town 300 km from the nearest regional hospital. Relies on Aboriginal Health Worker for most medical contact. No internet or mobile coverage at home. Receives aged pension.

Examination findings: RR 22, HR 88, BP 132/82, SpO₂ 92% on room air. Barrel chest. Reduced breath sounds and expiratory wheeze bilaterally. No cyanosis. No peripheral oedema. No signs of acute infection.

Point-of-care testing: CRP 4 mg/L (normal), FBC normal. Spiro not available today. Last spirometry 18 months ago: FEV₁/FVC 0.62, FEV₁ 54% predicted.

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

Jockie Ryan, a 12-year-old boy from a cattle station 250 km from your rural clinic, is brought in by his mother with a 2-day history of fever, headache, and rash. He has also been complaining of joint and muscle pain. His mother mentions that he has been helping on the property and had ticks removed from behind his ear and back last week. There is no known contact with COVID-19. He has had all scheduled childhood vaccinations.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives on a remote station in inland Queensland. Home-schooled. Drinking bore water. No recent travel.

Examination findings: T 38.9°C, HR 110 bpm, BP 100/65 mmHg. Maculopapular rash on trunk and extremities, including palms and soles. Mild conjunctival injection. No neck stiffness. Mild hepatomegaly. Alert but tired-appearing. No focal neurological signs. No petechiae or bruising.

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

Janice Black, a 33-year-old woman living on a remote cattle station in the NT, presents via telehealth with a 4-day history of increasing right breast pain and swelling. She is currently breastfeeding her 6-week-old daughter. She describes the breast as hot, painful, and red, with some flu-like symptoms and a subjective fever overnight. There is no nipple trauma, but feeding has been more difficult on the affected side.

Medications: Nil

Allergies: Nil known

Past history: Nil significant. First pregnancy.

Social history: Lives 300 km from the nearest town. No immediate access to a hospital or pathology services. A community midwife visits once per fortnight.

Examination findings (via video): Area of erythema and induration over upper outer quadrant of the right breast. No visible abscess or fluctuation. Appears uncomfortable and tired but not acutely unwell. Baby is visible and appears well-fed. Janice is afebrile on her home thermometer.

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

Graham Palmer, a 58-year-old man living in a small rural town in WA, presents with recurrent episodes of dizziness and near-syncope while working on his farm. He describes a ‘spinning’ sensation that comes on when he turns his head or gets out of bed quickly. The episodes last less than a minute and resolve spontaneously. He denies chest pain, palpitations, or hearing loss. There is no associated headache or visual aura. He has a history of hypertension and takes perindopril 5 mg daily.

Medications: Perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension

Social history: Lives on a farm 120 km from nearest regional centre. No alcohol. Ex-smoker (20 pack-years, quit 10 years ago). No known ATSI background. No internet access.

Examination findings: BP 130/80 mmHg, HR 76 bpm regular, neurological exam normal. Ears appear normal. Dix-Hallpike test on the right side reproduces vertigo with torsional nystagmus. Romberg test negative. No gait ataxia. No other abnormalities.

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

Margaret Forrester, a 66-year-old woman living on a sheep farm in western NSW, presents to your rural GP clinic with chronic fatigue, poor appetite, and intermittent low-grade fevers for the past 6 weeks. She reports night sweats and 3 kg weight loss. Her past history includes osteoarthritis and treated breast cancer 12 years ago. She drinks unpasteurised goat milk from her own herd and helps with lambing season. She has no recent overseas travel.

Medications: Paracetamol prn

Allergies: Nil known

Past history: Osteoarthritis, breast cancer (treated, no recurrence)

Social history: Lives with her husband on the property, 90 km from the nearest town. Manages livestock daily. No ATSI background. Non-smoker, drinks 1–2 glasses of wine on weekends.

Examination findings: T 37.7°C, HR 86, BP 128/78. Mild hepatosplenomegaly. No lymphadenopathy. No joint swelling or rash. Cardiovascular and respiratory exams normal.

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

Tommy Coulton, a 9-year-old Aboriginal boy, is brought to your remote clinic in northern WA by his grandmother with a 2-week history of worsening ear pain, intermittent fever, and discharge from his right ear. She reports that his hearing seems worse and he’s been having trouble following instructions at school. He’s otherwise well. He lives in a remote community with overcrowded housing and limited access to regular health checks.

Medications: Nil

Allergies: Nil known

Past history: Multiple episodes of otitis media in early childhood

Social history: Lives with extended family, community school, remote location, no mobile reception. Speaks local language and English. Up to date with vaccinations.

Examination findings: T 37.4°C, HR 88, BP 105/70. Thick purulent discharge in right ear canal. On otoscopy, tympanic membrane is not visible. Tenderness behind the ear. Mild conductive hearing loss on tuning fork tests. No mastoid swelling. Left ear normal.

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

Steven McIntyre, a 29-year-old stockman living in a remote NT community, presents with sudden-onset right scrotal pain that started 6 hours ago while mustering cattle. The pain is constant, severe, and associated with nausea. He denies trauma, urinary symptoms, or fever. There is no previous history of testicular issues. He drove himself 90 minutes to reach your rural clinic.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives alone in a station donga. Limited phone coverage. No ATSI background. No alcohol or drug use. No children. Sexually active with female partner.

Examination findings: Appears distressed. T 36.9°C, HR 96, BP 135/82. Right testis is swollen, tender, high-riding and with absent cremasteric reflex. No discharge. No hernia. Left testis normal. No costovertebral angle tenderness.

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

Theresa Bell, a 52-year-old woman, presents to your small rural clinic in northern SA with increasing shortness of breath, bilateral ankle swelling, and abdominal bloating over the past month. She also reports loss of appetite and a sensation of fullness in her abdomen. Her past medical history includes chronic hepatitis B diagnosed 20 years ago and treated hypertension. She has not been seen in several years and has not had regular monitoring.

Medications: Irbesartan 150 mg daily

Allergies: Nil known

Past history: Hepatitis B (untreated), hypertension

Social history: Lives in a remote town 400 km from the nearest regional centre. Drinks 2–3 standard drinks most days. No ATSI background. Works seasonally in a roadhouse. No recent travel.

Examination findings: BP 110/70 mmHg, HR 88 bpm, RR 18, SpO₂ 97%. Moderate ascites, bilateral pitting oedema, spider naevi, palmar erythema. Mild confusion noted during history-taking. No jaundice. Abdomen soft, non-tender. No peritonism.

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

Michael Tui, a 37-year-old seasonal worker originally from Samoa, presents to your rural GP clinic in northern Queensland with a three-month history of increasing shortness of breath and dry cough. He reports fatigue and reduced exercise tolerance. He works on a banana plantation and lives in shared accommodation with other seasonal workers. He is a non-smoker and has no significant medical history. He has not seen a doctor since arriving in Australia eight months ago.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Seasonal agricultural worker. No fixed address. Speaks English as second language. No known ATSI background. Non-drinker.

Examination findings: T 37.1°C, HR 92, BP 120/76, RR 18, SpO₂ 95% on room air. Bibasal fine crackles on auscultation. No wheeze. Normal heart sounds. No peripheral oedema or clubbing.

Investigations: CXR (performed onsite): bilateral reticulonodular infiltrates predominantly in upper zones. Full blood count normal. HIV negative. Quantiferon Gold positive.

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

Alinta Cook, a 19-year-old Aboriginal woman, presents to your remote clinic in central Australia with heavy menstrual bleeding and increasing fatigue over the past 4 months. She reports soaking through pads every 2 hours on her heaviest days and describes bleeding lasting 7–8 days per cycle. She feels tired all the time, has difficulty concentrating, and sometimes feels dizzy when standing. She has no known medical conditions and is not sexually active.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with extended family in a remote community. Left school last year. Limited access to transport and women’s health services. No mobile reception. Diet is low in fresh vegetables. No alcohol, smoking or drug use.

Examination findings: Pale conjunctivae, BP 98/60, HR 94 bpm, no bruising or petechiae. Abdomen soft, non-tender. No pelvic masses or signs of infection.

Point-of-care testing:

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

Gary Malthouse, a 63-year-old retired mechanic, presents to your rural GP clinic with a 2-month history of persistent right shoulder pain and weakness. He reports difficulty lifting his arm above shoulder height, especially when hanging laundry or reaching into cupboards. There was no acute injury, but he recalls a “twinge” while lifting a heavy item in his shed. He has used over-the-counter analgesics with minimal relief. He lives on a remote property 150 km from the nearest imaging facility and has no private health insurance.

Medications: Paracetamol prn

Allergies: Nil known

Past history: Type 2 diabetes, hypertension

Social history: Lives with wife on rural acreage. Non-smoker. Previously active but now limited due to shoulder symptoms. No ATSI background.

Examination findings: No swelling or redness. Limited active abduction and external rotation of the right shoulder. Passive range full but painful. Positive painful arc between 60–120°. Weakness on resisted abduction and external rotation. No neurological deficits. No cervical spine tenderness or symptoms.

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

Wendy Muir, a 46-year-old woman from a remote desert community in WA, presents to your clinic with persistent thirst, nocturia, and recent unintentional weight loss of 6 kg over 2 months. She has also developed a fungal rash under her breasts and reports blurred vision. She has not seen a doctor in over five years. Her father had diabetes, and two of her siblings are also diabetic.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Lives with extended family in a remote Aboriginal community. Diet includes sweetened tea, white bread, and canned foods. Smokes 10 cigarettes/day. Limited access to transport. No internet or phone at home.

Examination findings: BMI 29 kg/m², BP 145/92, HR 82 bpm. Acanthosis nigricans at neck folds. Mild fungal rash under both breasts. No focal neurological deficits. Fundoscopy limited due to poor lighting.

Point-of-care testing:

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

Colin Hume, a 47-year-old stockyard worker, presents to your rural clinic after sustaining a crush injury to his left hand from a cattle gate 90 minutes ago. He reports intense pain, swelling, and numbness in the fingers. There was no open wound, but the hand was trapped and compressed for nearly a minute. He is right-handed. The nearest hospital with imaging is 180 km away.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives and works on a remote cattle station. No ATSI background. Drinks socially, non-smoker. No regular medical contact.

Examination findings: The left hand is swollen, tense, and exquisitely tender. Capillary refill is delayed in all fingers. Passive extension of the fingers causes severe pain. Radial pulse palpable. No obvious deformity or open injury.

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

Jasmine Ng, a 23-year-old woman on a working holiday visa from Malaysia, presents to your rural general practice in northern Tasmania with complaints of fatigue, shortness of breath on exertion, and frequent bruising over the past month. She has also noticed some gum bleeding when brushing her teeth. She works in a local berry-picking farm and lives in shared seasonal accommodation. She does not recall any recent illness, fever, or infections.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with other seasonal workers. Diet is mostly rice, noodles, and canned food. Limited access to fruit and fresh vegetables. No alcohol or drugs. No ATSI background.

Examination findings: Pale conjunctivae, petechiae on both lower limbs, and mild gingival hypertrophy with bleeding. No lymphadenopathy. No hepatosplenomegaly. Vitals normal. No signs of infection or trauma.

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

Brian Coulter, a 76-year-old man, presents to your small rural hospital emergency department with sudden onset left-sided weakness and slurred speech that began 45 minutes ago while he was working in his garden. He has a history of hypertension and atrial fibrillation, for which he takes warfarin. He lives 90 minutes by road from the nearest CT scanner. There is no dedicated stroke team on site, and retrieval by air may be delayed due to weather.

Medications: Warfarin 5 mg daily, perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, atrial fibrillation

Social history: Lives with wife on rural property. Independent in activities of daily living. No ATSI background.

Examination findings: GCS 15, BP 148/84, HR 82 (irregular), RR 16, SpO₂ 96%. NIHSS estimated 8. Left facial droop, left arm and leg weakness, dysarthria. No seizure activity. No trauma. Capillary glucose 6.2 mmol/L.

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

Harriet O’Sullivan, a 34-year-old primary school teacher living in a remote inland NSW town, presents with a 2-week history of low mood, early morning waking, fatigue, and difficulty concentrating. She feels increasingly overwhelmed, especially since a recent bushfire threatened her home and disrupted school operations. She denies thoughts of self-harm or suicide. She reports that services locally are limited and she feels isolated. Her partner works away two weeks at a time. No history of mental illness.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives in a farming community of 900 people. Strong community ties but limited access to psychological services. No alcohol or drug use. No ATSI background.

Examination findings: Appears tired and tearful. Affect low. Speech slow but coherent. No delusions or hallucinations. Insight intact. Physical exam unremarkable.

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

Russell Dyer, a 61-year-old man from a remote NT cattle station, presents to your rural clinic with increasing difficulty swallowing solids over the past 3 months. He describes a sensation of food ‘sticking’ in his lower chest and occasional regurgitation of undigested food. He has also noticed a 7 kg unintentional weight loss. There is no history of heartburn, cough, or vomiting blood. He has not seen a doctor in years and has no known medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil recorded

Social history: Lives alone, long-term smoker (40 pack-years), drinks 3–4 beers daily. No ATSI background. Eats mainly tinned and preserved food due to location.

Examination findings: BMI 19.3, appears cachectic. No lymphadenopathy or organomegaly. No oral lesions. Chest and abdominal examinations unremarkable.

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

Frankie Martin, a 9-year-old Aboriginal boy, is brought to your remote clinic by his grandmother with concerns about increasing fatigue and dark-coloured urine over the past week. He had a sore throat about three weeks ago but did not receive antibiotics. His grandmother also notes that his face looks ‘puffy’ in the mornings. He has no history of chronic illness and is usually active and healthy.

Medications: Nil

Allergies: Nil known

Past history: No known chronic disease. Immunisations up to date.

Social history: Lives in overcrowded housing in a remote community. Access to fresh food and healthcare is limited. No recent travel. No alcohol, tobacco, or drugs. Speaks local language and some English.

Examination findings: BP 132/88 mmHg (elevated for age), pulse 90 bpm, afebrile. Mild periorbital oedema, no rash. Urine dipstick: 3+ blood, 2+ protein. No costovertebral angle tenderness. Weight: 29 kg (normal for age). No hepatosplenomegaly.

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

Leonard ‘Len’ Wilcox, a 59-year-old shearer living in a remote Victorian town, presents to your rural clinic with a chronic non-healing ulcer on his right lower leg. He first noticed a small scab following a minor graze six weeks ago, which gradually worsened. The ulcer is now 2.5 cm in diameter, shallow, with a yellow sloughy base and surrounding erythema. He reports no fever but describes the area as itchy and painful at night. He continues to work and wears boots daily. His diabetes was diagnosed last year but has not been reviewed since. He smokes 15 cigarettes daily.

Medications: Nil

Allergies: Nil known

Past history: Type 2 diabetes (poorly followed-up), smoker, hypertension (diagnosed 5 years ago)

Social history: Lives alone in basic accommodation, no vehicle, limited access to allied health. Diet is mostly tinned and processed food. No ATSI background.

Examination findings: Ulcer on right anterior shin, no obvious purulence, surrounding erythema, sluggish capillary refill in foot, pedal pulses diminished. Random BSL 13.9 mmol/L. No signs of systemic illness. Mild peripheral neuropathy in both feet.

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

Sylvia Connors, a 31-year-old woman, presents to your rural GP clinic in western NSW with concerns about ongoing fatigue, weight gain, and feeling constantly cold despite the warm weather. She also reports constipation, dry skin, and reduced concentration. Her last pregnancy was three years ago. She lives on a remote farm and has limited access to regular medical care. There is no family history of thyroid disease.

Medications: Nil

Allergies: Nil known

Past history: Gestational diabetes (resolved), no current chronic illness

Social history: Lives with husband and two children, 60 km from nearest town. Does not smoke or drink alcohol. Diet is largely meat and preserved foods, with limited fresh produce. No ATSI background.

Examination findings: HR 56 bpm, BP 118/78, weight 82 kg, BMI 29.6. Skin dry and cool to touch. Mild facial puffiness. Reflexes show delayed relaxation phase. No goitre or neck tenderness. No tremor. No palmar erythema.

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

George Lang, a 67-year-old retired farmer, presents to your rural GP clinic in south-west Queensland with worsening breathlessness over the past six months. He reports a chronic dry cough, mild chest tightness, and reduced ability to keep up with farm activities. He is a non-smoker but worked in shearing sheds and used dry hay daily for many years. He has no history of asthma or COPD and takes no medications.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with wife on property. No ATSI background. Retired but helps with seasonal work. No alcohol or tobacco. No occupational exposure since retiring 2 years ago.

Examination findings: T 36.7°C, HR 78, BP 134/82, RR 18, SpO₂ 95% on room air. Bibasal fine inspiratory crackles. No wheeze. No peripheral oedema. Finger clubbing present.

Investigations: CXR: Bilateral reticular opacities in lower zones. Spirometry: FEV₁/FVC ratio 0.80, FVC 62% predicted, TLC reduced. DLCO 50% predicted.

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

Naomi Burns, a 25-year-old woman from a remote mining town in WA, presents to your rural clinic with a 2-month history of increasingly painful and irregular periods, pain during sex, and lower back discomfort. She has been trying to conceive with her partner for the past year without success. She has never been pregnant and has no significant medical history. There is no local gynaecology service and ultrasound access is limited to visiting services every 6 weeks.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner. Works in administration for the local mine. No alcohol or drug use. No ATSI background. No family history of infertility or endometriosis.

Examination findings: BP 116/74, HR 74. Bimanual exam: Retroverted uterus, tender posterior fornix, no adnexal masses palpable. Mild tenderness on deep palpation of pelvis. No discharge or signs of infection.

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

Trevor Gill, a 72-year-old retired station hand, presents to your rural emergency department with confusion and unsteady gait. His neighbour found him wandering near his home and brought him in. He has been increasingly withdrawn over recent weeks, and reportedly has been drinking more heavily since his wife died six months ago. There is no known history of dementia or seizures. He has not attended a doctor in years.

Medications: Unknown

Allergies: Nil known

Past history: Nil documented. No known chronic disease.

Social history: Lives alone in remote area. Drinks 6–8 beers daily. Eats mostly tinned foods and bread. Smokes 20 cigarettes/day. No ATSI background. Very limited social support.

Examination findings: Confused and inattentive. BP 118/76, HR 96, RR 16, T 36.6°C, SpO₂ 97%. Ataxic gait. Horizontal nystagmus present. No focal neurological deficits. No signs of trauma. Mild bilateral lower limb weakness.

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

Emily Zhao, a 36-year-old woman, presents to your remote GP clinic in far north Queensland with a painful, swollen right calf. She reports that the pain started two days ago and has been worsening. She recently returned from a 15-hour car trip visiting family interstate. She has no history of trauma, fever, or recent illness. She works from home as a freelance writer and spends long hours sitting. She has no previous clots, is not on the pill, and has regular periods.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives in a rural property with partner and children. No ATSI background. Non-smoker. Drinks socially.

Examination findings: T 36.9°C, HR 84, BP 122/76, RR 14, SpO₂ 98% on room air. Right calf is swollen (3 cm larger than left), tender on deep palpation, and warm to touch. No skin changes elsewhere. No signs of infection. Peripheral pulses present and symmetric.

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

Maisie Rowe, a 3-year-old girl, is brought to your rural clinic by her mother with a 3-day history of fever, decreased oral intake, and a red rash on her hands and feet. Her mother reports that Maisie attends a local daycare centre and that several other children have been sick with “blisters on their mouths.” Maisie has been irritable and has refused food since yesterday. She has no vomiting or diarrhoea.

Medications: Nil

Allergies: Nil known

Past history: Healthy and developmentally normal

Social history: Lives on a property 40 km from town. Attends daycare 3 days a week. Up to date with immunisations. No ATSI background.

Examination findings: T 38.5°C, HR 110, RR 24, SpO₂ 98% on room air. Erythematous maculopapular rash on palms and soles, small vesicles on soft palate and buccal mucosa, mildly erythematous throat. No signs of dehydration. Chest clear, abdomen soft.

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

Jackie Petersen, a 48-year-old woman living on a remote cattle station in far western Queensland, presents with a 4-month history of increasing abdominal bloating, early satiety, and intermittent lower abdominal discomfort. She has also experienced some fatigue and noticed that her clothes fit more tightly around the waist. She has had no recent medical reviews and has not had a Pap smear in over 10 years. Her last menstrual period was 8 months ago.

Medications: Nil

Allergies: Nil known

Past history: Nil significant. Three vaginal deliveries, all uncomplicated.

Social history: Lives with husband on a remote property. Non-smoker. Drinks occasionally. No ATSI background. Limited access to transport and healthcare.

Examination findings: BMI 26, abdomen distended with shifting dullness, mild lower abdominal tenderness, no masses palpable. No peripheral oedema. Pelvic exam: fullness in the adnexal region, no cervical discharge or lesions. Bowel sounds present and normal.

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

Angus Ritchie, a 62-year-old sheep grazier, presents to your rural clinic with a three-month history of persistent cough and progressive shortness of breath. He describes the cough as dry and worse with exertion. He also notes increased fatigue and has lost about 5 kg unintentionally over the past few months. He has a 45-pack-year smoking history and quit five years ago. He lives over 100 km from the nearest regional centre with imaging facilities.

Medications: Nil

Allergies: Nil known

Past history: Chronic bronchitis diagnosed 10 years ago, no known cancer history

Social history: Lives alone, previously worked in shearing sheds and wool classing. No ATSI background. No current alcohol or drug use.

Examination findings: Cachectic appearance, BMI 19.4, RR 20, HR 92, BP 130/84, SpO₂ 95% on room air. Mild clubbing. Decreased breath sounds in right upper zone, dullness to percussion. No peripheral oedema. Cardiac exam normal.

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

Yvonne Miller, a 54-year-old woman from a remote South Australian community, presents with worsening lower limb swelling and fatigue over several months. She also reports mild shortness of breath on exertion, early satiety, and right upper quadrant discomfort. She has a history of obesity and was diagnosed with type 2 diabetes five years ago but has not had recent follow-up. She is not currently on any medications and has limited access to health care.

Medications: Nil

Allergies: Nil known

Past history: Type 2 diabetes (poorly followed-up), obesity, hypertension (undiagnosed, no medications)

Social history: Lives with extended family. No ATSI background. No alcohol or drug use. Diet is largely processed food. No recent travel. No regular transport to town.

Examination findings: BP 148/92, HR 84, RR 16, SpO₂ 97%. BMI 38. Pitting oedema to knees bilaterally. Jugular venous pressure not elevated. Abdomen distended, non-tender, with shifting dullness. Mild hepatomegaly. No stigmata of chronic liver disease. No signs of DVT. Heart sounds dual and normal.

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

Lachlan Barrett, a 17-year-old high school student, presents to your rural clinic in western NSW with ongoing daytime sleepiness and difficulty concentrating. He describes falling asleep in class and waking unrefreshed despite 9–10 hours of sleep each night. He has a history of loud snoring and his parents report gasping episodes during sleep. His BMI is 33 kg/m². There is no history of drug use or mood disorder. He is otherwise healthy and takes no medications.

Medications: Nil

Allergies: Nil known

Past history: Childhood asthma (resolved), no current medications

Social history: Lives with parents on a sheep property. Attends local high school. Non-smoker. No alcohol use. No ATSI background. No recent travel.

Examination findings: BP 124/76, HR 78, RR 16. BMI 33 kg/m². Mallampati score III. No craniofacial abnormalities. ENT exam: enlarged tonsils, no nasal polyps. Cardiovascular and respiratory exams normal.

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

Donald Brown, a 79-year-old widower, is brought to your small rural clinic by his neighbour after a recent fall at home. He tripped over a mat and was found on the ground after several hours. He is alert but reports unsteadiness, generalised weakness, and recent memory lapses. He lives alone on a sheep farm 70 km from the nearest town. There is no home support in place and no recent medical review.

Medications: Amlodipine 10 mg daily (started 6 months ago)

Allergies: Nil known

Past history: Hypertension, osteoarthritis (knees), presbycusis

Social history: Lives alone, no family nearby. Retired farmer. Limited mobility and drives infrequently. No ATSI background. No alcohol or tobacco use.

Examination findings: BP 132/74 sitting, 104/68 standing. HR 82, regular. Mild bruising on left hip. Unsteady gait. Rinne and Weber suggest bilateral sensorineural hearing loss. GCS 15. No focal neurology. MMSE: 24/30.

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

Rangi Te Paea, a 42-year-old Māori man, presents to your rural GP clinic in northern Tasmania with several months of fatigue, dry cough, and skin lesions on his shins. He also reports intermittent joint stiffness, particularly in the morning. He migrated from New Zealand five years ago and works in forestry. He has no known chronic conditions and takes no regular medications. There is no weight loss or fever.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Lives with wife and children. Works outdoors year-round. Non-smoker, drinks socially. No ATSI background.

Examination findings: Vitals normal. Bibasal crackles on lung auscultation. No wheeze. Multiple erythematous, tender nodules on anterior lower legs (consistent with erythema nodosum). Mild synovitis in both wrists. No lymphadenopathy. No clubbing.

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

Annabelle Thomas, a 30-year-old Aboriginal woman, presents to your remote GP clinic in the Kimberley region of WA with a painful, swollen right knee. The symptoms began two days ago without trauma. She has had intermittent joint pain and stiffness in her hands and feet over the past few months. She also reports morning stiffness lasting about an hour. She has difficulty accessing regular care and has not had blood tests or imaging recently.

Medications: Nil

Allergies: Nil known

Past history: No formal diagnoses. Multiple pregnancies, all healthy deliveries.

Social history: Lives in a remote Aboriginal community. Cares for three children. Limited transport. Smokes 5 cigarettes/day. Diet lacks fresh produce due to availability.

Examination findings: Right knee warm, swollen, and tender with reduced range of motion. Mild swelling and tenderness in MCP and PIP joints bilaterally. No fever. Vitals stable. No skin lesions. No conjunctivitis or rash. No signs of trauma or effusion elsewhere.

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

Colleen Dwyer, a 61-year-old woman, presents to your remote clinic in western NSW with worsening fatigue, shortness of breath on exertion, and swollen ankles over the past month. She has a long-standing history of rheumatic heart disease diagnosed in her teens but has not had follow-up for over 15 years. She was born and raised in a rural town and has lived on the same sheep property her entire life. She is not currently on any medications.

Medications: Nil

Allergies: Nil known

Past history: Rheumatic heart disease (childhood diagnosis, no follow-up), one episode of rheumatic fever at age 13

Social history: Lives with husband, no regular transport, no access to local cardiology. No ATSI background. Never smoked. Minimal alcohol use.

Examination findings: BP 108/64, HR 92 irregularly irregular, RR 22, SpO₂ 94% on room air. Bibasal crackles, elevated JVP, displaced apex beat. Pitting oedema to knees. Soft mid-diastolic murmur best heard at the apex. Irregular rhythm. No fever.

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

Dean Murray, a 45-year-old Aboriginal man, presents to your remote NT clinic with a two-day history of fever, malaise, and a painful swelling on his left foot. He recently helped slaughter cattle on a nearby station. He has a small ulcerated lesion over the dorsum of his left foot, which he first noticed after stepping on a stick several days ago. He now has rigors and is feeling increasingly unwell. He has not seen a doctor in over a year.

Medications: Nil

Allergies: Nil known

Past history: Type 2 diabetes (undiagnosed until now), occasional heavy alcohol use

Social history: Lives with family in a remote community, relies on community clinic for care. High-risk environmental exposure (soil, water, livestock). Smokes 10 cigarettes/day.

Examination findings: T 39.4°C, HR 112, BP 96/64, RR 22, SpO₂ 95% RA. Drowsy but rousable. Ulcer on left foot with surrounding cellulitis and purulent discharge. Mild hepatomegaly. No other focal signs of infection. Capillary BSL 18.3 mmol/L.

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

Erin Wallace, a 29-year-old schoolteacher, presents to your rural clinic in inland Victoria with a three-day history of fever, dry cough, and increasing shortness of breath. She returned from a weekend hiking trip in the Grampians five days ago. Several of her friends who were on the trip also felt unwell. She has no past medical history, takes no regular medications, and is a non-smoker. She is fully vaccinated for COVID-19 and influenza.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives locally, works at a regional school. No alcohol or drug use. No recent overseas travel.

Examination findings: T 38.1°C, HR 102, RR 20, SpO₂ 95% on room air. Bibasal crackles on auscultation. No rash, lymphadenopathy, or wheeze. Chest X-ray shows patchy lower lobe infiltrates bilaterally.

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

Jacob McKellar, a 51-year-old sheep shearer, presents to your rural South Australian clinic with a six-month history of progressive numbness and tingling in both feet. He also describes a burning sensation in his toes at night and recent unsteadiness when walking on uneven ground. He reports drinking 6–8 beers daily for many years and has a diet primarily consisting of tinned meats and white bread. He has never been diagnosed with diabetes and has no known chronic conditions.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Lives alone in a rural cottage. No ATSI background. Minimal healthcare access. Non-smoker.

Examination findings: BP 132/78, HR 84, normal cardiorespiratory exam. Bilateral loss of vibration and pinprick sensation in feet up to mid-calf. Ankle reflexes absent bilaterally. Mild gait ataxia observed. No skin ulceration or calluses. Romberg positive.

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

Ruth Canning, a 72-year-old woman, presents to your rural clinic in western Victoria with a 4-day history of worsening confusion, nausea, and muscle weakness. Her family notes she has become increasingly lethargic and forgetful. She has a history of hypertension and osteoporosis and has been taking hydrochlorothiazide for over 10 years. She lives independently on a farm with support from her daughter who visits weekly.

Medications: Hydrochlorothiazide 25 mg daily, calcium carbonate + vitamin D

Allergies: Nil known

Past history: Hypertension, osteoporosis

Social history: Lives alone. No ATSI background. Independent in daily activities. No alcohol or smoking.

Examination findings: BP 108/68, HR 76, RR 16, SpO₂ 98% on room air. GCS 14 (slightly drowsy), no focal neurological signs. Mild generalised weakness. ECG: prolonged QT interval.

Investigations (point-of-care):

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

Mohammed Al-Masri, a 34-year-old man recently settled in a rural NSW town as a refugee from Syria, presents to your general practice with a chronic cough, fatigue, and occasional night sweats. He has lost approximately 4 kg over the past two months. He denies haemoptysis or chest pain. He has no known past medical history and has not accessed Australian healthcare previously. He lives with his wife and two children in community housing. He does not smoke or drink alcohol.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Recently arrived under humanitarian visa. Unemployed. Attends local English language classes. No ATSI background.

Examination findings: T 37.6°C, HR 86, RR 18, SpO₂ 97% on room air. Mild crackles in the right upper zone. No lymphadenopathy. No clubbing.

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

Theresa Holloway, a 26-year-old woman, presents to your rural GP clinic in far western NSW with persistent lower abdominal pain, abnormal vaginal discharge, and low-grade fevers for the past 6 days. She reports dyspareunia and dysuria but no vomiting. She has had two new sexual partners in the past three months and uses condoms inconsistently. She has no significant medical history and is not currently using contraception.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives on a sheep station, 60 km from town. No ATSI background. No children. Accesses healthcare via mobile GP service. No recent travel.

Examination findings: T 38.1°C, HR 96, BP 112/70. Mild suprapubic tenderness. Bimanual exam: cervical motion tenderness, adnexal tenderness on the right, no palpable mass. Speculum: mucopurulent cervical discharge. No peritonism. Urinalysis negative for nitrites and leukocytes.

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

Glen Robertson, a 68-year-old retired station worker, presents to your rural clinic in central Queensland with worsening shortness of breath on exertion, non-productive cough, and fatigue over the past four months. He previously smoked for 40 years but quit five years ago. He reports occasional wheeze but no chest pain or haemoptysis. He lives 150 km from the nearest hospital and has limited transport options. He last saw a doctor more than a year ago.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (not currently medicated)

Social history: Lives alone in remote accommodation. Ex-smoker, 40 pack-years. No ATSI background. Limited access to health services.

Examination findings: BP 134/78, HR 88, RR 18, SpO₂ 94% on room air. Chest auscultation: decreased breath sounds bilaterally, fine inspiratory crackles at bases. No peripheral oedema or clubbing.

Investigations: Spirometry (portable): FEV1/FVC 0.78, FEV1 62% predicted, FVC 60% predicted, reduced DLCO. CXR (done in town 3 days ago): bilateral lower zone reticular opacities.

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

Hannah Walker, a 23-year-old university student on placement in a remote NT Indigenous community, presents to your clinic with worsening fever, headaches, and general malaise over the past 5 days. She has recently returned from a weekend camping trip in a tropical area where she swam in freshwater creeks. She reports muscle aches, nausea, and photophobia. She is otherwise healthy and takes no regular medications.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Visiting remote area for public health placement. No ATSI background. No recent overseas travel. No regular GP.

Examination findings: T 38.6°C, HR 94, BP 114/74, RR 18, SpO₂ 97% on room air. No rash. Mild conjunctival suffusion. No neck stiffness. Mild hepatomegaly. No lymphadenopathy. Alert and oriented.

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

Barry Franklin, a 74-year-old man, presents to your remote clinic in western Queensland with progressive difficulty swallowing solids over the past two months. He has also experienced unintentional weight loss of 6 kg and a persistent hoarse voice. He denies haematemesis or chest pain but notes occasional coughing while eating. He lives alone on a cattle station and rarely seeks medical attention. He is a lifelong smoker (60 pack-years) and drinks 2–3 beers daily.

Medications: Nil

Allergies: Nil known

Past history: Chronic bronchitis, no surgeries or prior cancer diagnoses

Social history: Lives in a remote location with no family nearby. No ATSI background. Smoker. Limited access to transport or imaging facilities.

Examination findings: Thin appearance, BMI 18.2. Mild cervical lymphadenopathy. No oral lesions or masses. Chest auscultation: scattered wheezes. Cranial nerves intact. Swallowing assessment: coughing triggered by liquids.

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

Leonie Brown, a 58-year-old Aboriginal woman, presents to your remote health service in northern WA with persistent low back pain and generalised fatigue for the past 3 months. She also reports unintentional weight loss of 5 kg and recurrent headaches. She has a known history of poorly controlled type 2 diabetes and chronic kidney disease stage 3. She is a lifelong non-smoker and drinks alcohol only occasionally. Access to imaging and pathology is limited locally.

Medications: Metformin, perindopril

Allergies: Nil known

Past history: Type 2 diabetes (15 years), CKD stage 3, hypertension

Social history: Lives in a remote Aboriginal community, cares for grandchildren. Limited transport. Speaks local language and English.

Examination findings: BP 136/82, HR 88, afebrile. Tenderness on lumbar spine percussion. Mild pallor. No neurological deficits. No lymphadenopathy. Mild hepatomegaly. BMI 21. No focal infection signs.

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