AKT – Aboriginal and Torres Strait Islander Health

Jacinta McKenzie, aged 52, a Gumbaynggirr woman, presents for a routine health check at your rural general practice. She has a known history of type 2 diabetes, hypertension, and hyperlipidaemia. She has not seen a GP in over 18 months. Her last HbA1c was 9.2%. She reports no new symptoms, but you note that she has not had any recent diabetic foot or eye screening.

She smokes 15 cigarettes daily and drinks approximately 2–3 standard drinks every evening. She takes metformin and amlodipine but has not filled her statin prescription in over 12 months.

Her BP is 148/92 mmHg, BMI 32.

What is the MOST appropriate next step in her care?

Michael Walker, aged 17, a Wiradjuri teenager, is brought in by his aunt for behavioural issues at school. He has become increasingly withdrawn and irritable and has been suspended twice in the past 6 months. He has no current suicidal ideation but expresses feelings of hopelessness and trouble sleeping.

He lives with extended family in overcrowded housing and recently lost his uncle, with whom he was close. He is not taking any medications and has no history of mental illness.

What is the MOST appropriate next step in managing this patient?

Aaron Dhurrkay, aged 35, a Yolŋu man, presents to your remote clinic for a follow-up after being treated for latent TB. He completed a 6-month isoniazid course. He is asymptomatic today. His wife is pregnant and he has 3 children under 10. He works as a ranger and smokes 10 cigarettes per day.

You review his immunisation history and note he has never received pneumococcal vaccination.

What is the MOST appropriate vaccine to offer Aaron today?

Maree Thompson, aged 24, a Noongar woman in her second trimester of pregnancy, presents for a routine antenatal visit. She has a BMI of 36, smokes intermittently, and was diagnosed with gestational diabetes last week. She lives in a regional town and receives shared care through your practice and the local Aboriginal Medical Service.

Her HbA1c today is 6.2% and her fasting BSLs have ranged from 5.5 to 6.2 mmol/L.

What is the MOST appropriate management at this point?

Trevor Cox, aged 68, a Bundjalung man, presents with a 6-month history of chronic cough, 6 kg unintentional weight loss, and night sweats. He lives in a regional town, is a current smoker (20/day), and worked in mining for 30 years. He has no regular GP.

On examination, he appears thin but is not in respiratory distress. His chest X-ray shows a left upper lobe cavitary lesion.

What is the MOST appropriate next step?

Clara Rankine, aged 45, an Anangu woman, presents with a non-healing ulcer on her right lower leg. She reports it started as an insect bite 3 weeks ago. She has type 2 diabetes and peripheral vascular disease. She lives in a remote community. Examination reveals a 3 cm ulcer with slough and surrounding erythema. Pulses are weak and there is associated peripheral neuropathy.

What is the MOST appropriate next step?

Alinta Fraser, aged 29, a Yorta Yorta woman, presents requesting contraception. She has had 3 unplanned pregnancies, all resulting in live births. She has a new partner and is unsure what method would be suitable. She has no past medical history. She does not smoke or take any medications.

She prefers a low-maintenance and long-term option.

What is the MOST appropriate contraceptive option to discuss first?

Corey Dunbar, aged 11, a Kamilaroi boy, presents with a persistent ear discharge for the past 6 weeks. His mother says it started after a cold. He has mild hearing loss in the affected ear and intermittent low-grade fevers. Examination reveals a perforated tympanic membrane with mucopurulent discharge.

What is the MOST appropriate next step in management?

Joyce Carter, aged 61, a Tiwi Islands woman, presents with increasing breathlessness and dry cough. She has a long history of rheumatic heart disease and underwent mitral valve replacement 5 years ago. She is on warfarin. INR today is 1.6.

She lives remotely and has limited access to pathology services.

What is the MOST appropriate immediate management?

Levi Mundine, aged 6, a Dharug boy, presents with fatigue and poor growth. His mother reports he is often tired and doesn’t seem to be thriving like his cousins. On examination, he is pale and has a systolic flow murmur. You order blood tests that show Hb 85 g/L, MCV 68 fL, low serum ferritin, and raised ESR.

What is the MOST likely underlying cause of his anaemia?

Elaine Riley, aged 58, a Wangkangurru woman, presents for follow-up after an admission with an NSTEMI. She was discharged on aspirin, atorvastatin, metoprolol and ramipril. She lives alone in a remote town, is newly diagnosed with diabetes, and has no car. She is unsure how she will attend cardiac rehab or get her scripts filled regularly.

What is the MOST appropriate next step to address her care?

Steven Pascoe, aged 38, a Warlpiri man, presents with general fatigue and joint aches. He has a long history of alcohol misuse but has been abstinent for 3 months. On examination, he is jaundiced, with hepatomegaly and spider naevi. Bloods show AST 120, ALT 75, GGT 400, ALP 200, bilirubin 55 and INR 1.5. Hepatitis B surface antigen is positive.

What is the MOST appropriate next investigation?

Lena Brown, aged 42, a Kalkadoon woman, presents for a cervical screening test. Her last screen was 8 years ago. She reports no symptoms and has not been sexually active for 2 years. She had a traumatic first Pap smear in her teens and is anxious about the procedure.

What is the MOST appropriate next step?

Kevin Gill, aged 55, a Barkindji man, presents with worsening breathlessness and ankle swelling. He had acute rheumatic fever as a child. On examination, you note a diastolic murmur and bibasal crackles. He has not seen a specialist in years. ECG shows AF with a ventricular rate of 110. CXR shows pulmonary congestion.

What is the MOST likely cause of his symptoms?

Aaliyah Doolan, aged 14, a Torres Strait Islander girl, is brought by her grandmother for review of chronic skin sores. They appear mostly on her legs and arms, and are often pustular or crusted. She has received multiple courses of oral antibiotics over the past year. Her school attendance is poor and she is shy and withdrawn during the consult.

What is the MOST appropriate next step?

Mark Bray, aged 47, a Noongar man, presents for a routine review. He has schizophrenia and takes clozapine. He lives in supported accommodation but often misses appointments. He smokes and has gained 12 kg in the last year. His BP is 145/92, fasting glucose is 7.8 mmol/L, and triglycerides are elevated.

What is the MOST appropriate management to reduce his cardiovascular risk?

Linda Thorne, aged 36, a Warumungu woman, presents with ongoing pelvic pain and dyspareunia. She has had multiple STIs in the past and uses condoms inconsistently. She is not currently trying for pregnancy. Examination reveals cervical motion tenderness. Urine PCR returns positive for chlamydia.

What is the MOST appropriate next step in management?

Trevor Austin, aged 62, a Kuku Yalanji man, presents with chest pain and shortness of breath. He has a history of type 2 diabetes and renal impairment. Troponin is mildly elevated and ECG shows non-specific ST changes. His eGFR is 42 and creatinine is 155.

What is the MOST appropriate next step in management?

Chloe Dingo, aged 16, a Luritja girl, presents with tiredness and heavy menstrual bleeding. She became sexually active 6 months ago. Her BMI is 19 and she looks pale. FBE shows Hb 78 g/L, MCV 70 fL, and ferritin 8 μg/L. Her periods last 8–10 days, and she is not using contraception.

What is the MOST appropriate initial management?

Patrick Harris, aged 69, a Ngarrindjeri man, presents to discuss prostate cancer screening. He has no urinary symptoms and no family history of prostate cancer. He has heard conflicting information and is unsure whether to proceed.

What is the MOST appropriate approach?

Darryl Johnson, aged 31, a Barkly region man, presents to your outreach clinic with persistent insomnia and irritability. He reports recent exposure to community violence, poor sleep, nightmares and hypervigilance. He avoids people and has lost interest in hunting. There is no alcohol or drug use.

What is the MOST likely diagnosis?

Yvonne Turner, aged 49, a Gumbaynggirr woman, presents for a cervical screening test. She had her last test 6 years ago and has now received her first HPV self-collected result, which is high-risk positive. She is asymptomatic.

What is the MOST appropriate next step?

Graham Walker, aged 67, a Wiradjuri man, presents with unintentional weight loss and fatigue. He has a 45 pack-year smoking history. He lives rurally and rarely sees a GP. Examination is unremarkable. You order blood tests and a chest X-ray which shows a right hilar mass.

What is the MOST appropriate next step?

Nathan Rowe, aged 25, a Wajarri man, presents with painful urination and urethral discharge. He is sexually active with both men and women and does not consistently use condoms. You suspect a sexually transmitted infection.

What is the MOST appropriate initial management?

Kayla Davis, aged 9, a Kija girl, presents with recurrent sore throats. She has had 4 episodes of tonsillitis in the last 6 months. She lives with extended family in overcrowded housing. On review, her throat is erythematous with enlarged tonsils but no pus or lymphadenopathy.

What is the MOST appropriate strategy to reduce recurrence?

Arnold Gibbs, aged 72, a Yolŋu elder, presents with progressive memory loss, disorientation and word-finding difficulty. His daughter reports he sometimes gets lost in his own neighbourhood. He has a history of hypertension and hearing impairment. His MoCA score is 19/30.

What is the MOST appropriate next step in management?

Joey Malbunka, aged 3, a Central Desert child, is brought in by his uncle for a chronic cough and wheeze. He has had multiple admissions for chest infections. He is fully vaccinated. On examination, he has wet-sounding cough, clubbing and mild respiratory distress. CXR shows bronchial wall thickening and hyperinflation.

What is the MOST likely diagnosis?

Rachel Ah Mat, aged 28, a Torres Strait Islander woman, presents requesting preconception advice. She has type 1 diabetes and recently stopped contraception. HbA1c is 8.5%. She takes insulin glargine and novorapid. No other medical history.

What is the MOST important next step?

Dennis Riley, aged 61, a Ngemba man, presents for routine review. He has a history of CKD stage 3b, hypertension, and gout. He reports knee stiffness and is struggling with his weight. BP is 138/84, eGFR 42. Current medications include allopurinol, perindopril, and paracetamol as required.

What is the MOST appropriate recommendation for his joint symptoms?

Travis Peters, aged 22, a Yorta Yorta man, presents to your AMS clinic with a swollen, painful right knee after playing footy. He has fever and difficulty weight-bearing. He has a history of childhood rheumatic fever and no regular GP. Joint is warm and erythematous.

What is the MOST important next step?

Mary Ellis, aged 51, a Pitjantjatjara woman, presents for a health check. She is postmenopausal, has smoked for 30 years, and has a family history of hip fracture. Her BMI is 22 and she does not take calcium or vitamin D. She spends most of her time indoors due to heat.

What is the MOST appropriate screening test?

Jeremy Tilmouth, aged 6, an Arrernte boy, presents with scabies. He lives in an overcrowded household with several siblings who are also scratching. On examination, he has excoriated lesions on his limbs and torso, and impetigo on his legs.

What is the MOST appropriate first-line treatment?

Ashley Gilbert, aged 43, a Darumbal woman, presents with abdominal bloating, change in bowel habits and early satiety. She has unintentionally lost 6 kg in 3 months. She has no past medical history and no family history of bowel cancer.

What is the MOST appropriate next step?

Wayne Watson, aged 59, a Bundjalung man, presents with poorly controlled type 2 diabetes. His HbA1c is 9.8%, BP 154/96 and eGFR 60. He takes metformin and gliclazide. He missed his last 2 reviews and reports difficulty understanding the medication instructions.

What is the MOST appropriate next step to improve his outcomes?

Kaleb Morrison, aged 40, a Torres Strait Islander man, presents requesting help with quitting smoking. He has smoked 20 cigarettes daily since age 15. He has no major medical conditions but is worried about his long-term health. He is ready to quit but unsure how.

What is the MOST effective initial approach?

Jodie Lennon, aged 33, a Kuku Yalanji woman, presents in her third trimester with increasing shortness of breath. She has known rheumatic heart disease with mitral stenosis. She is currently 34 weeks pregnant. On examination, she has a loud diastolic murmur and basal crackles. BP is 110/70, HR 96 bpm, RR 22.

What is the MOST appropriate next step?

Pauline Ryder, aged 44, a Barkindji woman, presents with fatigue, low mood, and weight gain. She had a baby 8 months ago and reports difficulty sleeping and lack of interest in usual activities. She has no suicidal ideation. Edinburgh Postnatal Depression Scale score is 17.

What is the MOST appropriate next step?

Brian Thomas, aged 50, a Warlpiri man, presents with persistent epigastric pain, early satiety and weight loss. He smokes heavily and drinks 6–8 beers daily. On exam, he is cachectic with epigastric tenderness. Hb is 96 g/L, MCV 84, ALT 48, ALP 220, bilirubin 28.

What is the MOST likely diagnosis?

Tanika Williams, aged 26, a Tiwi woman, presents at 10 weeks gestation. She smokes 10 cigarettes per day and has a BMI of 18. She has no other medical history. She is uncertain about what supplements to take and is worried about the baby’s health.

What is the MOST important supplement to recommend?

Stephen Gorey, aged 58, a Gunggari man, presents for review of his asthma. He reports increasing use of salbutamol and waking 3–4 nights per week with cough. He is currently prescribed salbutamol PRN only. He lives in a dusty rural environment and smokes 5–10 cigarettes per day.

What is the MOST appropriate next step?

Debbie Yunupingu, aged 30, a Yolŋu woman, presents for antenatal care at 20 weeks gestation. She lives in a remote community. She has no significant past history. Her BP is 142/88 and urine dipstick shows + protein. There is no oedema.

What is the MOST appropriate next step?

Raymond Shields, aged 61, a Yamatji man, presents with a skin lesion on his forearm that has been slowly enlarging over 3 months. It is scaly, crusted, and bleeds occasionally. He works outdoors and has never had skin checks before.

What is the MOST likely diagnosis?

Tahlia Cook, aged 18, a Murri woman, presents requesting contraception. She is in a new relationship and has a history of heavy periods and iron deficiency. She is not planning pregnancy for the next few years.

What is the MOST appropriate contraceptive option to recommend?

Isaac Freeman, aged 5, a Gubbi Gubbi boy, is brought in with a 3-day history of fever, reduced oral intake, and sore throat. On exam, he has tonsillar exudate, cervical lymphadenopathy and a sandpaper-like rash. Rapid strep test is positive.

What is the MOST appropriate treatment?

Layla Knox, aged 47, a Wongatha woman, presents with persistent fatigue and recurrent mouth ulcers. She has been vegan for 5 years and takes no supplements. On examination, she is pale. Bloods show Hb 98 g/L, MCV 110 fL, low B12, and normal folate.

What is the MOST appropriate treatment?

Francis Murray, aged 68, a Yawuru man, presents for review of his COPD. He has had 3 exacerbations in the past 12 months, and is currently on salbutamol and tiotropium. He continues to smoke. Recent spirometry confirms FEV1 at 45% predicted.

What is the MOST appropriate next step in his management?

Jasmine Napurrula, aged 3, presents with her mother to your remote clinic with a history of lethargy and pallor. She has a known history of failure to thrive. On exam, she is pale with a systolic murmur. Her diet is poor, mainly white bread and cordial. Hb is 72 g/L, MCV 60 fL, ferritin is 4 μg/L.

What is the MOST appropriate treatment?

Peter Doolan, aged 39, a Torres Strait Islander man, presents requesting STI screening. He has recently been released from prison and has had new partners. He is asymptomatic.

What is the MOST appropriate STI screening panel to order?

Natalie Cubillo, aged 27, a Larrakia woman, presents with ongoing sadness, poor concentration and low energy. She experienced a miscarriage 2 months ago and has withdrawn from family. She reports thoughts of worthlessness but no active suicidal ideation.

What is the MOST appropriate first step in management?

Leonard Webb, aged 55, a Ngemba man, presents with dizziness on standing. He has type 2 diabetes and is taking metformin and gliclazide. His seated BP is 130/80 and standing BP is 105/68. He reports no recent falls.

What is the MOST likely cause of his symptoms?