AKT – Justice system health

Marcus Dutton, aged 34, presents to the prison clinic with a three-week history of worsening fatigue, night sweats and a productive cough with blood-streaked sputum. He has been incarcerated for the past 12 months. He denies intravenous drug use but reports sharing a cell with someone recently treated for ‘chronic chest infection’.

He is a lifelong smoker. Past history includes depression and a remote episode of community-acquired pneumonia. No recent travel or known contacts outside prison. He takes no regular medications.

On examination: T 37.9°C, HR 96, RR 20, SpO₂ 97% RA. Chest examination reveals crackles in the right upper zone. CXR shows right upper lobe cavitation.

What is the most appropriate next step?

Kelly Freeman, aged 29, presents for a routine medication review at the correctional facility clinic. She has a history of schizophrenia and has been stable on risperidone depot for the last 18 months. She discloses increasing concern about weight gain, missed periods, and recent galactorrhoea.

No history of illicit drug use. She is compliant with her medications and denies hallucinations or delusions. No family history of endocrine disorders.

On examination: BMI 31 kg/m², normal BP, galactorrhoea on expression. Serum prolactin is 980 mIU/L (N < 500).

What is the most appropriate management?

Damien O’Connell, aged 19, is brought to the prison medical unit after a physical altercation with another inmate. He is agitated, verbally aggressive, and difficult to engage. He reports being persecuted by other inmates and believes the guards are poisoning his food. He has no previous contact with mental health services.

On examination: Speech is pressured, affect is labile, thought content reveals persecutory delusions. No signs of intoxication. Vitals are stable.

What is the most appropriate next step in management?

Elena Tran, aged 46, presents to the custodial health clinic with complaints of severe dental pain and facial swelling. She reports a long-standing dental issue that worsened over the last week. She has been incarcerated for 6 months and is on methadone maintenance therapy.

On examination: left-sided facial swelling, trismus, and tenderness along the mandible. She is febrile at 38.5°C. Swelling appears fluctuant. No airway compromise.

What is the most appropriate next step in management?

Tommy Jalal, aged 52, is a long-term inmate with a history of hepatitis C, alcohol dependence and hypertension. He presents for routine care and reports lethargy and muscle cramps. He takes perindopril 5 mg daily. Recent bloods show: Na 127 mmol/L, K 4.4 mmol/L, Cr 85 µmol/L, eGFR >60.

He denies fluid overload, vomiting or diarrhoea. He reports drinking excess water from boredom. Weight stable. Medications unchanged for 6 months.

What is the most likely diagnosis?

Andrew Fenech, aged 43, is serving an 8-year sentence. He presents to the prison clinic requesting hepatitis C treatment. He was diagnosed 2 years ago but did not follow up. He has no cirrhosis on FibroScan done 6 months ago, no current alcohol use, and has been abstinent from injecting drugs since incarceration.

Past medical history includes depression and mild asthma. He takes sertraline and salbutamol. He is keen to engage with treatment and expresses guilt over past transmission risk.

What is the most appropriate management plan?

Bryce Kelly, aged 36, requests opioid replacement therapy (ORT) while on remand. He has a 15-year history of heroin use and has previously been on methadone in the community. He reports severe cravings, anxiety and poor sleep since being incarcerated 3 days ago. He is open to restarting treatment and engaging in counselling.

On examination: he is sweating, restless, and has dilated pupils. Vitals are within normal limits.

What is the most appropriate next step?

Natalie Bassi, aged 28, is 34 weeks pregnant and incarcerated for drug-related offences. She presents with increasing shortness of breath and bilateral leg swelling. She has no past medical history. There are no signs of DVT. BP 130/80, HR 98, RR 22, O₂ sat 95% RA. Fundal height consistent with dates, fetal heart rate 145 bpm. Urinalysis is normal.

What is the most appropriate next investigation?

John Malik, aged 62, has been incarcerated for 18 months. He presents with memory difficulties, emotional lability, and occasional confusion. His cellmate reports that John has become withdrawn and forgetful. He has a history of chronic alcohol use and was treated for hepatitis C three years ago. No history of trauma or psychiatric illness.

On examination, he is oriented to person but not place or time. Neurological exam is non-focal. He scores 21/30 on MMSE.

What is the most likely diagnosis?

Raymond Tsai, aged 41, is serving a sentence in a rural correctional facility. He reports being bullied by other inmates and is fearful for his safety. He has no psychiatric history and denies hallucinations or suicidal thoughts. He has self-isolated in his cell and avoided meals. Staff report he’s become withdrawn and appears anxious.

On review: BP 128/76, HR 78, appears fatigued and avoidant. Mental state examination shows anxious mood, reduced speech, no formal thought disorder. He agrees to support but fears retaliation if he speaks out.

What is the most appropriate next step?

Samira Okeke, aged 33, is in a metropolitan correctional centre and requests contraception. She has a history of bipolar disorder managed with lithium and has two children in out-of-home care. She is currently sexually active with one partner within the prison. She denies STI history and is not planning further pregnancies.

She reports good adherence to medications and regular menstrual cycles. She prefers something long-acting and reversible.

What is the most appropriate contraceptive option?

Luke Tran, aged 39, has type 2 diabetes and is serving a 3-year sentence. He presents with ongoing foot pain and a non-healing ulcer under the 1st metatarsal head, present for 4 weeks. He has poor glycaemic control and smokes 20 cigarettes daily. Examination shows a 1.5 cm ulcer with surrounding erythema, no discharge. Pulses are weak, capillary refill is delayed.

What is the most important next step in management?

Charlie Benson, aged 45, is incarcerated and has a history of PTSD from early childhood trauma and previous military service. He reports nightmares, hypervigilance and insomnia. He is not currently taking medications and declines referral to psychiatry, stating he has had poor experiences in the past. He is open to counselling and behavioural strategies.

What is the most appropriate initial approach?

Aleksandar Milosevic, aged 50, reports urinary frequency and poor stream. He has been in prison for 5 years. He denies haematuria, dysuria or constitutional symptoms. There is no relevant family history. On examination, the prostate is smooth, moderately enlarged and non-tender. Urinalysis is normal.

What is the most appropriate next investigation?

Jason Taukamo, aged 27, is on remand and identifies as Aboriginal. He presents to the clinic requesting help to quit smoking. He has no other significant health issues. He reports smoking 20–25 cigarettes per day for 10 years. He is motivated to quit, especially with a newborn child on the outside. He prefers not to use tablets and wants to try patches.

What is the most appropriate management?

Mehdi Al-Sayeed, aged 38, is in prison for the first time. He discloses a history of torture and detention in his country of origin and is seeking asylum. He reports insomnia, flashbacks, and poor concentration. He denies current suicidal ideation but appears distressed and withdrawn. He has not accessed any mental health services previously and is wary of authority.

What is the most appropriate initial approach to his care?

Shelley White, aged 31, is a transgender woman housed in a male correctional facility. She presents to the prison GP to request continuation of her gender-affirming hormone therapy, which she has been using via private prescription prior to incarceration. She expresses distress that her oestradiol was ceased on admission. She is otherwise healthy and compliant with medications.

What is the most appropriate next step?

Wayne Delbridge, aged 57, has chronic hepatitis B and was recently transferred from another correctional facility. He is asymptomatic and reports no history of treatment. Routine labs show ALT 42 U/L, HBV DNA 7.8 log10 IU/mL, HBeAg positive. No cirrhosis on ultrasound. FibroScan not yet available. He is interested in starting treatment.

What is the most appropriate next step?

Monique Ellis, aged 23, is on remand for drug offences. She reports recent unprotected sex, irregular periods, and mild pelvic discomfort. She is worried about pregnancy and has never had a Pap smear. Examination is declined. A urine pregnancy test is negative. STI screening is offered. She is open to contraception.

What is the most appropriate next step?

Glenn McAdam, aged 48, is due for release next month after serving a 4-year sentence. He has type 2 diabetes, hypertension and major depressive disorder. He is currently stable on metformin, perindopril and sertraline. He asks about getting his scripts and referrals sorted before release as he is worried he won’t see a doctor straight away.

What is the most appropriate discharge planning action?

Travis Yilmaz, aged 29, presents to the prison clinic with severe dental pain and requests ‘something strong’. He has a history of opioid use disorder and is on buprenorphine-naloxone. Examination reveals a decayed molar with visible caries and mild surrounding swelling. He is afebrile and systemically well.

What is the most appropriate next step?

Bridget Zhang, aged 36, is currently incarcerated and is known to have a borderline personality disorder. She presents after superficial wrist lacerations, stating she feels overwhelmed. This is her third such incident in 2 weeks. She is calm and cooperative during the consultation, denies suicidal intent and asks to speak with mental health.

What is the most appropriate management?

Ian Johnston, aged 44, is in prison for assault charges. He has a history of schizophrenia, managed with depot paliperidone. Staff report recent agitation, insomnia and responding to unseen stimuli. On assessment, he is guarded and suspicious, and he believes that the guards are conspiring against him.

What is the most appropriate next step?

Julie Namatjira, aged 54, is an Aboriginal woman in custody for the first time. She presents with insomnia, anxiety, and low mood. She has no previous mental health history and is worried about her family on the outside. She agrees to support but prefers to ‘talk to someone’ instead of starting tablets.

What is the most appropriate initial management?

Peter Manolas, aged 47, is a long-term prisoner with known ischaemic heart disease. He complains of increasing exertional chest pain over the past week. He is compliant with medications including aspirin, atorvastatin and bisoprolol. Vitals are stable, ECG shows non-specific ST-T changes, and troponin is normal.

What is the most appropriate next step?

Mohammed Issa, aged 26, is a refugee and new arrival in custody. He presents with vague abdominal pain, fatigue, and weight loss. He denies drug use. He reports spending time in a refugee camp in East Africa. Examination shows mild hepatomegaly. Bloods reveal eosinophilia and mild anaemia. LFTs show mildly elevated ALT and ALP.

What is the most appropriate next investigation?

Eric Wu, aged 59, is an insulin-dependent diabetic in prison. He reports frequent hypoglycaemic episodes before lunch. He eats meals in the prison mess but reports variable timing of breakfast and insulin administration. There have been no recent changes to his insulin regimen.

What is the most appropriate management strategy?

Hemi Rawiri, aged 35, is an Aboriginal man serving an 18-month sentence. He presents with a scaly, crusted lesion on the scalp, which has been slowly enlarging. He recalls frequent sun exposure and has fair skin. Examination reveals a 1.5 cm raised, firm, non-tender lesion with overlying scale.

What is the most appropriate next step?

Vince Hall, aged 63, has COPD and reports increasing shortness of breath on exertion in prison. He is on tiotropium and salbutamol inhalers. He continues to smoke despite counselling. Examination reveals scattered wheezes and prolonged expiration. O₂ sat is 92% RA. Spirometry is requested.

What spirometry result would confirm the diagnosis of COPD?

Kristy Barlow, aged 29, is 28 weeks pregnant and in prison for non-violent offences. She presents with fatigue and low mood. She has a history of iron deficiency anaemia and was previously prescribed iron, which she has not taken regularly. FBE shows Hb 91 g/L, MCV 72 fL, ferritin 8 µg/L.

What is the most appropriate management?

Corey Nguyen, aged 42, is newly incarcerated and presents to the clinic with known HIV on antiretroviral therapy. His medications include tenofovir, emtricitabine and dolutegravir. He is concerned that he missed two doses since transfer due to delays in medication supply.

What is the most appropriate action?

Susan Riley, aged 47, is incarcerated and presents with new-onset urinary incontinence. She describes urgency and occasional leakage during the day. She has no dysuria or haematuria. Past history includes multiple vaginal births. Urinalysis is normal. Pelvic exam is unremarkable and no pelvic masses are palpable.

What is the most appropriate initial management?

Arman Hussain, aged 30, recently transferred from another facility, reports difficulty sleeping and agitation. He is known to have generalised anxiety disorder and has previously been managed with escitalopram. On checking, his medications were not continued after transfer.

What is the most appropriate next step?

Trent Wallace, aged 24, is on remand and presents with scabies confirmed by skin scraping. He has extensive excoriations over the trunk and limbs. Several inmates in the same wing have similar symptoms. He is distressed by the itching and embarrassed by the appearance.

What is the most appropriate management plan?

Alana Peters, aged 39, is serving a sentence for fraud. She discloses a history of childhood sexual abuse and experiences of coercive control in a past relationship. She presents with chronic pelvic pain, worsened by stress, and no identifiable organic cause despite previous investigations.

What is the most appropriate management approach?

Declan Fisher, aged 67, is an inmate with chronic schizophrenia. He presents with unsteady gait and new onset tremor. He has been on risperidone depot for over a decade. Examination reveals a coarse resting tremor, masked facies, and bradykinesia.

What is the most appropriate next step in management?

Sasha Petrov, aged 40, discloses during a mental health consult in custody that he is hearing voices telling him to harm others. He has a history of schizophrenia and was previously non-compliant with treatment. He appears dishevelled and distracted, with thought disorder and impaired insight.

What is the most appropriate immediate action?

Kelly Tanner, aged 25, presents with a request for STI screening. She is in a same-sex relationship and has no symptoms. She has never had a cervical screening test. She is otherwise healthy and on no regular medications.

What is the most appropriate next step?

Jackson Riley, aged 52, is nearing release and is on long-term opioid substitution therapy. He is concerned about access to his treatment after leaving prison. He lives in a rural area with limited services.

What is the most appropriate discharge planning intervention?

Ahmed Youssef, aged 36, is on remand and experiencing symptoms of acute withdrawal after recent heavy benzodiazepine use. He appears anxious and tremulous. He admits to using alprazolam daily for months. Vitals: HR 106, BP 148/92, no fever or hallucinations.

What is the most appropriate initial management?

Leanne Douglas, aged 32, is a remand prisoner with a known history of anorexia nervosa. She is underweight with a BMI of 16.2 and has amenorrhoea. She reports exercising in her cell and refuses meals from the prison kitchen. On exam, she has bradycardia and cold peripheries. ECG shows sinus bradycardia, rate 48 bpm.

What is the most appropriate next step in management?

William Te Paa, aged 61, is an Aboriginal man serving a long sentence. He presents with chronic knee pain that limits his mobility. He has been using paracetamol and topical NSAIDs with partial relief. Examination reveals reduced range of motion and crepitus in the right knee. X-ray confirms severe osteoarthritis.

What is the most appropriate next step in management?

Fatima Ali, aged 26, is in custody and requests emergency contraception. She had consensual intercourse during a recent supervised visit and is not on regular contraception. She presents 36 hours after the event and is otherwise well. No past medical history.

What is the most appropriate management?

George Mikaere, aged 45, has schizophrenia and type 2 diabetes. He is found to have a fasting BGL of 16.8 mmol/L during routine check in prison. He reports feeling thirsty and urinating more frequently but denies weight loss. He takes olanzapine and metformin.

What is the most appropriate next step?

Tamara Grewal, aged 22, is an inmate with a history of ADHD. She reports feeling restless and unable to concentrate. She was previously on dexamphetamine but has not had any medication since incarceration 3 months ago. She has no history of substance misuse and is otherwise stable.

What is the most appropriate next step?

Joel Ritchie, aged 51, is serving a sentence and reports difficulty hearing over the past several months. He has no history of recent infections or trauma. He mentions he worked in a noisy factory for years prior to incarceration. Otoscopy is normal. Weber test lateralises to the left and Rinne test is positive bilaterally.

What is the most likely diagnosis?

Naomi Barbour, aged 37, is in prison and has a known history of PTSD and insomnia. She has been using diphenhydramine from canteen supplies to sleep. She reports poor sleep, vivid dreams, and daytime drowsiness. She is not on regular psychiatric medications.

What is the most appropriate next step in her care?

Bradley Knox, aged 33, is brought to the prison clinic by guards due to suspected psychostimulant intoxication. He is agitated, pacing, and paranoid. He has a history of methamphetamine use. Vitals: HR 128, BP 165/100, T 37.9°C. He is talking rapidly and intermittently shouting.

What is the most appropriate initial management?

Helena Cruz, aged 41, presents with vaginal discharge and lower abdominal discomfort. She has been incarcerated for 3 weeks and had unprotected sex just prior to arrest. On speculum examination there is mucopurulent cervical discharge. Pregnancy test is negative. She consents to STI screening.

What is the most appropriate immediate management?

Rangi Watene, aged 29, is an inmate with a known history of depression. He has missed multiple doses of sertraline since being transferred between facilities. He now reports dizziness, nausea, and ‘brain zaps’. He denies suicidal thoughts. Vitals are stable and examination is normal.

What is the most appropriate management?