KFP – Addiction medicine

Thomas Nguyen, aged 38, presents to your clinic requesting a refill of his alprazolam prescription. He reports increasing anxiety over the past several months due to job-related stress and relationship issues. He was initially prescribed alprazolam 1 mg three times daily by a GP he saw while travelling interstate 6 months ago, and he has since obtained repeat scripts from several GPs. He appears anxious during the consultation and repeatedly checks his phone. He reports running out of medication early most months and states he ‘can’t cope’ without it. He denies alcohol or illicit drug use and does not want to see a psychologist, saying, “only medication helps.”

Medications: Alprazolam 1 mg TDS (self-reported)

Allergies: Nil known

Past history: Anxiety (self-reported), no documented mental health care plans

Social history: Lives alone, works irregular hours as a rideshare driver

Psychiatric history: No formal diagnosis recorded

Examination findings: Anxious affect, pressured speech, tremor in both hands, no signs of psychosis or suicidal ideation

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

Linda Gresham, aged 28, presents to your inner-urban general practice for a repeat prescription of methadone. She has been in the local Opioid Substitution Therapy (OST) program for the past 8 months and is currently receiving 60 mg methadone daily through a community pharmacy. She reports feeling more stable since starting treatment but mentions she has recently missed 3 doses due to ‘sleeping in’ and feeling unwell. She also admits to occasionally using oxycodone tablets she buys ‘off a mate’ when anxious. She says she is ‘doing pretty well overall’ and does not want her script changed.

Medications: Methadone 60 mg daily, occasional non-prescribed oxycodone

Past history: Heroin use (5 years), Hepatitis C (treated), anxiety disorder

Social history: Lives with partner, currently unemployed, previously incarcerated for theft, no children

Examination findings: Mild pinpoint pupils, resting tremor, no signs of intoxication or withdrawal, rapport easily established

Investigations: Urine drug screen last week: Methadone positive, oxycodone positive, benzodiazepines negative

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

Kylie Mansell, aged 44, presents to your rural practice requesting sleeping tablets. She reports a six-month history of poor sleep due to ongoing pain in her knees and hips, related to her osteoarthritis. She also reveals that she has been drinking ‘half a bottle of wine’ most nights to help get to sleep. She is tearful and says she feels ‘worn out and hopeless’. She lives alone and works part-time as a cleaner. She has no children and is estranged from her family.

Medications: Paracetamol PRN, codeine phosphate 30 mg PRN (self-managed, variable use)

Allergies: Nil known

Past history: Osteoarthritis, previously treated for depression (on citalopram 4 years ago)

Social history: Lives in a small rural town, socially isolated, no car, limited access to services

Examination findings: Normal cardiovascular and respiratory examination. BMI 31. Joint tenderness in knees and hips, antalgic gait. Mildly dishevelled appearance.

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

Isaac Kelemete, a 22-year-old university student, presents with concerns raised by his girlfriend about his recent behaviour. Over the past six months, he has been frequently missing classes, sleeping during the day, and becoming increasingly isolated and irritable. On direct questioning, he admits to daily cannabis use for the past 18 months, stating that it helps him relax and sleep. He reports difficulty concentrating, lack of motivation, and worsening academic performance. He denies use of other substances, though he occasionally drinks alcohol socially. He is otherwise physically healthy, with no significant medical history.

Medications: Nil

Past history: Nil significant

Family history: Father has a history of bipolar disorder

Social history: Lives in student accommodation, works part-time in a bar, estranged from his family

Examination findings: Flat affect, slow speech, no formal thought disorder, no perceptual disturbance. Vitals normal. No signs of intoxication.

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

Geoffrey Wallace, aged 62, presents to your metropolitan practice with worsening fatigue, nausea, and weight loss. He has a long history of alcohol use, drinking approximately one bottle of spirits per day for the past 20 years. He has been previously hospitalised for pancreatitis and hepatic encephalopathy, and was advised to stop drinking but has continued to consume alcohol daily. He now lives alone in supported housing and has minimal social supports. He appears gaunt and has a visible hand tremor during the consultation.

Medications: Thiamine 100 mg daily, frusemide 40 mg daily, lactulose PRN

Past history: Alcohol-related liver disease, ascites, hepatic encephalopathy, recurrent pancreatitis

Examination findings: Jaundiced sclera, spider naevi, palpable liver edge, ascites, resting tremor, GCS 15, oriented to time and place

Investigations: LFTs: ALT 48 U/L (N <45), AST 122 U/L (N <45), GGT 435 U/L (N <60), Bilirubin 78 µmol/L (N <20), Albumin 28 g/L (N 35–50), INR 1.5 (N <1.2)

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

Emily Rojas, aged 33, presents to your suburban general practice for help with quitting smoking. She reports smoking around 20 cigarettes per day since age 17 and has attempted to quit multiple times using willpower and nicotine patches, but has always relapsed due to stress and cravings. She has a background of generalised anxiety disorder and is currently in a stable relationship. She works as a high school teacher and reports that smoking is her main coping mechanism during breaks and after work. She does not drink alcohol or use other drugs.

Medications: Sertraline 100 mg daily

Past history: Generalised anxiety disorder (diagnosed 5 years ago), iron deficiency anaemia

Social history: Non-drinker, lives with partner, no children, engaged in regular exercise

Examination findings: Normal cardiorespiratory exam, BP 118/70 mmHg, BMI 24, no clinical signs of chronic lung disease

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

Bradley Collins, aged 19, is brought in to your after-hours GP clinic by his mother after being found confused and disoriented at home. He had attended a music festival the day before. His mother reports he has a history of recreational drug use and had mentioned taking ‘a couple of pills’ the night before. He is now alert but appears anxious and restless. He admits to taking MDMA (ecstasy) and cannabis. He reports dry mouth, fatigue, and feeling ‘jittery’.

Medications: Nil

Past history: Occasional cannabis use, no prior hospitalisations, no diagnosed mental health conditions

Examination findings: BP 142/88 mmHg, HR 118 bpm, RR 20, Temp 37.8 °C, pupils dilated, tremor in both hands, hyperreflexia, no clonus or rigidity, GCS 15

Investigations: Urine drug screen positive for MDMA and THC, ECG: sinus tachycardia

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

Farah El-Rami, aged 47, presents to your general practice with concerns about her increasing use of over-the-counter codeine-containing analgesics for chronic headaches. She reports taking a combination analgesic containing paracetamol and codeine ‘whenever the pain gets bad’—which she estimates is now around 8–10 tablets per day. She initially started using them occasionally for menstrual migraines but has continued even after menopause. She admits to sometimes taking them ‘to feel better’ even if she doesn’t have a headache. She is worried she might be addicted and is scared to stop in case the headaches return.

Medications: OTC paracetamol/codeine tablets (~16–20 mg codeine per day), no prescribed medications

Past history: Migraine (self-reported), dysmenorrhoea (now resolved), no psychiatric diagnoses

Social history: Lives with partner, works in retail, no alcohol or illicit drug use

Examination findings: BP 124/78 mmHg, HR 72 bpm, no neurological deficit, tenderness over occipital muscles, no photophobia

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

Michael Donovan, aged 51, presents to your general practice at the request of his employer after missing multiple days of work. He is a machine operator in a manufacturing plant and has recently had two minor workplace incidents. He admits to drinking a six-pack of beer most nights and often a few shots of whisky after. He insists he is never drunk at work but often feels sluggish in the morning. He has not had any formal treatment for alcohol use and says he ‘drinks to relax’. He lives with his wife and teenage son and says they have recently been arguing about his drinking.

Medications: Nil

Past history: Hypertension (diagnosed 2 years ago, untreated), smoker (10/day)

Social history: Employed full-time, married, limited social support outside of family

Examination findings: BP 158/94 mmHg, HR 92 bpm, BMI 29, flushed face, tremor in hands, no hepatomegaly or signs of chronic liver disease

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

Jaspreet Kaur, aged 30, presents to your clinic for the first time. She is currently on a buprenorphine-naloxone (Suboxone) program, initiated six weeks ago at a community alcohol and drug service following years of heroin dependence. She has been attending daily dosing at a local pharmacy. Today, she requests a transfer of her prescribing to your practice, saying the commute to her current prescriber is difficult and she prefers a female GP. She is otherwise physically well and says she is committed to recovery. She asks whether she can move to take-home doses soon.

Medications: Buprenorphine-naloxone 12 mg daily

Past history: Heroin dependence (7 years), hepatitis C (treated successfully), PTSD (related to domestic violence)

Social history: Lives in transitional housing, not currently working, engaged in counselling, no current legal issues

Examination findings: Normal vital signs, no injection sites or signs of intoxication, engaging and well-groomed

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

Claudia Reyes, aged 26, presents to your general practice for a follow-up review after a recent emergency department presentation for deliberate self-poisoning. She took approximately 20 tablets of her prescribed quetiapine, combined with alcohol, after a fight with her partner. She was medically cleared and discharged with a recommendation for GP and mental health follow-up. Claudia has a history of borderline personality disorder (BPD) and alcohol misuse. She reports drinking 2–3 bottles of wine most nights and says she feels ‘numb unless I’m drinking or taking something’. She denies current suicidal intent but appears emotionally labile during the consultation.

Medications: Quetiapine 100 mg nocte

Past history: Borderline personality disorder, alcohol misuse, prior overdose x2 (non-lethal), sexual trauma

Social history: Lives alone, unemployed, estranged from family, recently ended relationship

Examination findings: Tearful, cooperative, no psychotic features, vitals stable, no intoxication noted

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

Raymond Cook, aged 72, presents for a routine check-up. He is generally well but mentions that he’s been having trouble sleeping and occasional muscle aches. On further questioning, he discloses that he has been taking codeine-containing analgesics most nights for the past several years. He says it ‘helps take the edge off’ and he sometimes washes it down with a glass of sherry. He buys the tablets online since they became prescription-only. He has not discussed this with any previous doctors as he is ’embarrassed’. He lives alone and is socially isolated following the death of his wife two years ago.

Medications: Aspirin 100 mg daily, atorvastatin 20 mg daily, OTC codeine-paracetamol (self-sourced)

Past history: Hyperlipidaemia, mild osteoarthritis, bereavement, no formal psychiatric history

Social history: Lives alone, no children, ex-smoker, occasional alcohol use, previously very active in the local RSL club

Examination findings: BP 132/80 mmHg, HR 76 bpm, gait slow but steady, no jaundice or hepatomegaly, mild tremor, pupils normal

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

Angela Whitlam, aged 36, presents to your clinic requesting help with ‘losing control’ over her use of prescription stimulants. She was initially prescribed dexamphetamine by a psychiatrist 5 years ago for adult ADHD, but her care was not continued after she moved interstate. She has since been sourcing dexamphetamine online and via friends. She reports taking up to 60 mg daily to manage fatigue and focus at work, as well as during social events. She says she can’t function without it. She has recently experienced palpitations and insomnia and feels her mood is increasingly unstable.

Medications: Dexamphetamine (non-prescribed, variable use)

Past history: Suspected adult ADHD, anxiety, mild hypertension

Social history: Works full-time as a marketing executive, drinks socially, smokes 5 cigarettes/day, lives alone

Examination findings: BP 146/90 mmHg, HR 96 bpm, anxious but cooperative, no tremor, pupils reactive, speech slightly pressured

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

Mitchell Tan, aged 41, presents to your clinic complaining of poor sleep, low energy, and weight gain. He reports using anabolic steroids intermittently over the past 3 years, initially to improve muscle mass and performance at the gym. He ceased use 6 months ago after experiencing mood swings and acne. Since then, he reports feeling increasingly fatigued, with decreased libido and erectile dysfunction. He has not discussed this with any previous doctor due to shame.

Medications: Nil

Past history: Nil significant medical history

Social history: Lives with partner, employed full-time in sales, regular gymgoer, no alcohol or recreational drug use

Examination findings: BP 126/80 mmHg, HR 68 bpm, BMI 28, mildly reduced testicular volume, otherwise unremarkable

Investigations: Blood tests reveal: Total testosterone: 5.2 nmol/L (Ref: 8.3–30.2), LH: 1.2 IU/L (Ref: 1.7–8.6), FSH: 1.6 IU/L (Ref: 1.5–12.4)

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

Deborah King, aged 64, presents for a medication review. She has been taking temazepam 10 mg nightly for sleep for the past 18 months, prescribed initially after the death of her husband. She reports that it ‘barely works now’ and that she sometimes takes two tablets to get to sleep. She denies using alcohol or other drugs and has never discussed the medication with anyone since it was first prescribed. She appears anxious when you suggest reducing the dose and asks, ‘What else am I supposed to do to sleep?’

Medications: Temazepam 10–20 mg nocte, atorvastatin 20 mg daily, esomeprazole 20 mg daily

Past history: Hyperlipidaemia, reflux, bereavement, insomnia

Social history: Retired, lives alone, two adult children interstate, limited social contact

Examination findings: Normal cardiovascular and neurological exam, BMI 27, mild tremor noted in hands, oriented and alert

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

Leo Johnston, aged 29, presents to your practice after being discharged from the emergency department two days ago following an episode of opioid overdose. He was found unconscious at home by a housemate and was given intranasal naloxone by paramedics. He admits to using heroin intermittently over the past 2 years, but recently started using daily. He reports increasing tolerance, withdrawal symptoms between doses, and escalating financial and legal problems. He expresses shame but says he is ‘ready to get help’.

Medications: Nil

Past history: Childhood trauma, no known medical conditions, no psychiatric diagnoses

Social history: Lives in shared housing, currently unemployed, not in contact with family, has prior convictions for possession

Examination findings: BMI 21, HR 74 bpm, BP 122/78 mmHg, pupils 2 mm, mild tremor, no signs of acute intoxication

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

Alison Barrett, aged 35, presents to your clinic requesting a refill of her prescription for gabapentin. She reports chronic back pain after a motor vehicle accident several years ago. She says gabapentin is the ‘only thing that helps’ and asks for a higher dose, saying her previous GP would sometimes prescribe extra when things were really bad. You note from her MyHealth record that she has had multiple recent prescriptions from different practices. She becomes irritable when asked further questions and insists she does not use any illicit drugs. She denies mental health concerns but admits to drinking ‘a few glasses of wine most nights’.

Medications: Gabapentin (self-reported 900–1800 mg daily, varying)

Past history: Chronic lower back pain post-MVA, anxiety (self-reported), previous oxycodone use (ceased 2 years ago)

Social history: Single, lives with her dog, unemployed, limited social supports

Examination findings: Normal neurological exam, no focal deficits, tense but cooperative, BP 130/82 mmHg, HR 82 bpm

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

Travis Hughes, aged 23, presents for a follow-up appointment after being referred by his university counsellor. He reports ongoing issues with gaming and cannabis use. He says he spends most of his time at home, smoking cannabis daily and playing online games for up to 12 hours a day. He recently failed two university units and has withdrawn from social activities. He says he feels anxious and low in energy when not gaming or using cannabis but denies suicidal thoughts. He acknowledges that his use is a problem but is unsure how to change.

Medications: Nil

Past history: Generalised anxiety (undiagnosed), social withdrawal since age 18

Social history: Lives with parents, no employment, limited offline social interaction

Examination findings: Flat affect, no psychotic features, appears malnourished, BMI 18, pupils equal and reactive, cardiovascular and neurological exams normal

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

Karen Mooney, aged 58, presents for review after being discharged from hospital following treatment for acute pancreatitis. She has a long-standing history of alcohol use and admits to drinking 1–2 bottles of wine daily. This is her third hospital admission for alcohol-related complications in the past 2 years. She expresses fear about her health and states, ‘I know I need to stop but I don’t know how.’ She reports tremors in the morning and drinking to feel ‘normal’. She has never engaged in formal treatment and has no current supports in place.

Medications: Omeprazole 20 mg daily, thiamine 100 mg daily (post-discharge)

Past history: Chronic alcohol use, acute pancreatitis, hypertension, reflux

Social history: Lives alone, divorced, estranged from children, ex-smoker

Examination findings: BP 140/85 mmHg, HR 84 bpm, hand tremor, jaundiced sclerae, no confusion, oriented to person/place/time

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

Hassan Al-Fayed, aged 45, presents to your practice following a referral from his workplace health and safety officer. He is employed as a forklift operator and recently failed a random workplace drug screen, which was positive for methamphetamine. He is distressed about possibly losing his job and admits to using methamphetamine ‘occasionally on weekends’ to stay awake and socialise. He denies being dependent and insists he is never under the influence at work. He asks for help but says he doesn’t think he needs rehab or ‘those kinds of programs’.

Medications: Nil

Past history: No diagnosed mental health issues, no chronic illness, previously smoked (ceased 3 years ago)

Social history: Lives with wife and two children, stable housing, no financial issues, denies other drug use or regular alcohol use

Examination findings: Alert, oriented, cooperative. No signs of intoxication. BP 128/78 mmHg, HR 76 bpm, BMI 26

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

Sandra Li, aged 39, presents to your general practice after being advised by her IVF specialist to stop smoking. She smokes approximately 15 cigarettes per day and has tried to quit twice in the past year using nicotine patches, but relapsed both times due to work stress. She is motivated to quit, particularly as she and her partner are preparing for another IVF cycle. She asks about medications that are ‘safe for fertility’ and says she’s willing to try anything that will help her stop smoking long term.

Medications: Folic acid 0.5 mg daily, vitamin D 1000 IU daily

Past history: Secondary infertility, polycystic ovarian syndrome (PCOS), mild anxiety (no medications)

Social history: Lives with partner, works in hospitality, drinks alcohol socially, no illicit drug use

Examination findings: BP 122/76 mmHg, HR 78 bpm, BMI 31, no abnormal findings on cardiorespiratory exam

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

Jordan Blake, aged 46, presents to your clinic seeking help with chronic insomnia. He has been purchasing and using over-the-counter melatonin and online ‘natural sleep aids’ for several years, with little improvement. On further questioning, he admits to regular overuse of diphenhydramine-containing sedatives (e.g. ‘night-time cold and flu’ tablets) and occasional use of codeine cough syrup to ‘wind down’ at night. He says he sometimes combines these with a glass or two of wine. He has not discussed this pattern with previous GPs and appears embarrassed. He works full-time in IT and says poor sleep is affecting his concentration and mood.

Medications: Diphenhydramine-containing OTC sedatives (self-directed), occasional codeine linctus (not prescribed)

Past history: None significant

Social history: Lives alone, drinks alcohol 2–3 nights per week, non-smoker

Examination findings: Appears tired but alert, pupils normal, vitals within normal limits, no signs of intoxication or withdrawal

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

Phillip Nguyen, aged 52, presents to your clinic for follow-up after being diagnosed with non-alcoholic fatty liver disease (NAFLD) during routine health screening. He denies alcohol use but admits to daily energy drink consumption (3–4 cans/day) and a growing dependence on over-the-counter caffeine tablets to stay alert at work. He is a truck driver working long shifts and says he feels irritable and shaky when he skips his usual dose. He denies using illicit drugs but reports poor sleep, frequent palpitations, and anxiety symptoms. He is not on any prescription medications.

Medications: Over-the-counter caffeine tablets (200 mg per dose, 2–3 times daily)

Past history: NAFLD, hypertension (diet controlled), overweight since mid-40s

Social history: Lives with partner, high job stress, sedentary lifestyle, 5–6 cups of coffee per day in addition to tablets

Examination findings: BP 138/86 mmHg, HR 98 bpm, BMI 31, anxious affect, no tremor or neurological deficits

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

Natasha Fielding, aged 31, presents to your practice for follow-up after being discharged from hospital for a seizure that occurred while she was at a music festival. She has no known history of epilepsy. Toxicology from the emergency department revealed high levels of GHB (gamma-hydroxybutyrate) and low levels of methamphetamine. She admits she has been using GHB ‘almost daily’ for the past 4 months, mainly to help with sleep and social anxiety. She reports needing to take it every few hours to avoid feeling shaky, sweaty, and anxious. She is frightened by the seizure and says she wants help to stop using.

Medications: Nil

Past history: Social anxiety (undiagnosed), prior recreational drug use (MDMA, cannabis)

Social history: Lives in a share house, works part-time in retail, not currently in a relationship

Examination findings: Tremulous, anxious, BP 136/88 mmHg, HR 104 bpm, alert and oriented, no signs of intoxication

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

Liam O’Connor, aged 40, presents for follow-up after being discharged from the emergency department following an episode of chest pain and palpitations. Investigations ruled out cardiac ischaemia. He admits he had consumed several energy drinks and used cocaine the night before during a social event. On further questioning, he reveals he has been using cocaine every weekend for the past 6 months, and occasionally during the week to ‘stay sharp’ at work. He reports poor sleep, reduced appetite, and increasing anxiety, but says he is ‘not addicted’ and doesn’t want to stop completely — just to use more safely.

Medications: Nil

Past history: None significant

Social history: Works in finance, lives with partner, occasional alcohol use, exercises regularly

Examination findings: BP 144/90 mmHg, HR 96 bpm, appears tense and restless, normal cardiovascular and neurological exams

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

Emily Zhao, aged 34, presents requesting assistance to reduce her use of nitrous oxide (‘nangs’). She reports using them recreationally at parties over the past 2 years, but more recently has been using up to 50–100 bulbs per day at home. She reports numbness in her fingers and toes, poor memory, and episodes of unsteadiness when walking. She is embarrassed but motivated to stop. She denies use of other substances and is otherwise healthy.

Medications: Nil

Past history: Nil significant medical history

Social history: Lives alone, works in hospitality, no current mental health support

Examination findings: Mild unsteadiness on tandem gait, decreased pinprick sensation in hands and feet, brisk reflexes, Romberg’s positive

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

George Wilson, aged 61, presents to your practice with fatigue, poor concentration, and a recent fall. His daughter, who accompanies him, is concerned about his increasing confusion and unsteady gait. She reports he has been drinking daily for decades — mostly wine and beer — and often forgets whether he has eaten or taken care of himself. He recently retired and has become socially isolated. He denies drinking ‘that much’ but admits to having a drink in the morning to ‘steady himself’.

Medications: None

Past history: Hypertension (untreated), no previous admissions or known liver disease

Social history: Lives alone, divorced, limited contact with friends

Examination findings: BP 130/80 mmHg, HR 88 bpm, tremor at rest, impaired short-term memory, wide-based gait, GCS 15, oriented to place but unsure of date

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

Zara Ahmed, aged 27, presents to your clinic seeking help to stop using benzodiazepines. She was initially prescribed alprazolam two years ago for panic attacks but has continued use despite no longer seeing her original prescriber. She now takes 2–3 mg daily, purchased online or from friends. She reports worsening anxiety, poor concentration, and fatigue. She has attempted to reduce her dose previously but experienced tremors, insomnia, and palpitations. She is motivated to stop but fearful of withdrawal.

Medications: Alprazolam (non-prescribed, self-administered 2–3 mg/day)

Past history: Panic disorder (diagnosed 2 years ago), no other mental health diagnoses

Social history: Lives with partner, works as a freelance graphic designer, no alcohol or illicit drug use

Examination findings: HR 88 bpm, BP 120/76 mmHg, anxious affect, no psychotic features, no tremor currently noted

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

Marcus Riley, aged 38, presents requesting help with kratom use. He began using kratom tea and capsules he purchased online to help manage chronic back pain after a work injury. He reports using it daily for the past 18 months, and now feels unable to stop. He describes withdrawal symptoms including irritability, diarrhoea, insomnia, and muscle aches when he tries to cut back. He says kratom helps him function but feels ‘hooked’ and is embarrassed to discuss it. He denies use of opioids, alcohol, or illicit drugs.

Medications: Nil

Past history: Chronic lower back pain (non-surgical), depression (self-reported, untreated)

Social history: Lives with wife and two children, previously employed as a carpenter, currently on WorkCover

Examination findings: BP 132/82 mmHg, HR 80 bpm, alert and oriented, no signs of acute distress, mild restlessness during interview

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

Clare Donnelly, aged 22, presents for assessment after her university referred her to your clinic due to repeated class absences and erratic behaviour on campus. She appears distracted, with pressured speech and frequent fidgeting. On further questioning, she admits to using over-the-counter pseudoephedrine tablets daily to ‘help focus and get through exams.’ She has also been purchasing stimulants such as modafinil and, occasionally, dexamphetamine from friends. She denies illicit drug use but admits to poor sleep and recent weight loss. She has never been formally assessed for ADHD but believes she has ‘always had trouble concentrating.’

Medications: Pseudoephedrine-containing cold tablets (self-administered daily), modafinil (non-prescribed, intermittent)

Past history: No formal diagnosis; no prior mental health care

Social history: University student, lives with two housemates, single, occasional alcohol use

Examination findings: BP 140/88 mmHg, HR 104 bpm, thin build, anxious affect, mildly pressured speech, pupils equal and reactive, no delusions or hallucinations

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

Thomas Randall, aged 55, presents to your clinic after recently being released from prison where he served an 18-month sentence for drug-related offences. He is on parole and wants to ‘stay clean’ but feels overwhelmed. He previously used heroin daily but began methamphetamine use while incarcerated. He has not used opioids since release but reports intense cravings and poor sleep. He is living in transitional housing and attending weekly parole meetings. He is not currently on any opioid replacement therapy but expresses interest in avoiding relapse.

Medications: Nil

Past history: Opioid dependence, recent methamphetamine use, hepatitis C (treated successfully in custody)

Social history: Unemployed, estranged from family, limited social support, under community corrections supervision

Examination findings: BP 128/78 mmHg, HR 84 bpm, appears tense, no signs of intoxication or withdrawal, BMI 23

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

Nicole Fraser, aged 29, presents to your clinic for help with quitting vaping. She has been using nicotine-containing e-liquids daily for the past three years, initially to stop smoking. She now vapes every 30–60 minutes while awake and reports withdrawal symptoms — including irritability, anxiety, and restlessness — when unable to vape at work or during travel. She has tried to quit twice but relapsed both times due to cravings and stress. She asks whether vaping is ‘less harmful’ and what options are available to help her stop completely.

Medications: Nil

Past history: Tobacco smoking (quit 3 years ago), mild generalised anxiety disorder

Social history: Works in retail, lives with partner, no alcohol or illicit drug use

Examination findings: Vitals normal, BMI 24, anxious affect, no respiratory signs

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

Anthony Petrovski, aged 63, presents for review of chronic shoulder pain following a rotator cuff injury 2 years ago. He has been taking over-the-counter codeine-paracetamol (purchased online) and uses it daily, reporting that ‘nothing else works.’ He admits taking 6–8 tablets per day and says he feels nauseous and ‘shaky’ when he skips a dose. He has not informed previous GPs about his codeine use, fearing judgment. He is worried he has become ‘addicted’ but does not know how to stop. He has a history of depression, currently untreated, and reports poor sleep and low mood.

Medications: Nil prescribed; OTC codeine-paracetamol (self-administered daily)

Past history: Rotator cuff tear (non-surgical), depression (previously treated with SSRIs), hypertension (diet-controlled)

Social history: Retired mechanic, lives with wife, no alcohol or tobacco use

Examination findings: BP 128/82 mmHg, HR 72 bpm, appears fatigued, no focal neurological signs

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

Ruby Tan, aged 18, is brought to your clinic by her mother due to concerns about sudden mood swings, poor sleep, and increasing isolation. Ruby recently started university and has stopped attending most of her classes. Her mother reports finding small canisters and balloons in Ruby’s room, along with energy drinks and vaping devices. Ruby initially denies any issues but eventually discloses frequent use of nitrous oxide (‘nangs’) at parties and occasionally while alone to ‘relax’. She reports using them multiple times per week and sometimes experiences tingling in her hands and feet. She is worried she might be ‘messing up her brain’ but doesn’t know how to stop.

Medications: Nil

Past history: Nil diagnosed mental health conditions, no previous medical issues

Social history: Lives at home with parents, started university this year, no alcohol or tobacco use reported

Examination findings: Alert but withdrawn, BMI 19, mild unsteadiness on heel-to-toe walking, diminished vibration sense in distal limbs, pupils normal

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

Kevin Lloyd, aged 48, presents for review of chronic low mood and fatigue. He reports drinking 4–6 beers most evenings after work and sometimes more on weekends. He denies blackouts or binge episodes but says he feels ‘flat and unmotivated’ without a drink. He has previously tried to reduce his alcohol intake but found it hard due to sleep disturbance and irritability. He works as a warehouse supervisor and says he’s never missed work due to alcohol. He’s seeking help because his partner has recently voiced concerns about his health and their relationship.

Medications: Nil

Past history: Mild depression (self-managed), overweight (BMI 28), no significant medical illnesses

Social history: Lives with partner, full-time employment, non-smoker, no illicit drug use

Examination findings: BP 138/84 mmHg, HR 76 bpm, no signs of liver disease, appears tired but otherwise well

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

Jared Singh, aged 26, presents following a recent panic attack at work. He reports high stress, insomnia, and intermittent chest tightness. On further questioning, he reveals daily cannabis use for the past five years, which he initially used to help sleep. He now smokes 2–3 cones every evening, stating he feels anxious when he tries to cut back. He has attempted to stop in the past but found himself irritable, unable to sleep, and craving cannabis. He says his job performance is suffering, and he feels ‘stuck in a cycle’. He is interested in stopping but unsure how to cope without it.

Medications: Nil

Past history: No formal psychiatric diagnosis, mild asthma (infrequent salbutamol use)

Social history: Works in hospitality, lives with housemates who also use cannabis, no alcohol or tobacco use

Examination findings: BP 124/76 mmHg, HR 86 bpm, mildly anxious, clear chest, no tremor or signs of acute withdrawal

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

Stephen Mulligan, aged 71, presents at the request of his daughter, who is concerned about his recent confusion, repeated falls, and increased forgetfulness. He admits to drinking 4–5 glasses of whisky daily, mostly in the evenings, which he has done for decades. He has retired from work and lives alone. He says he ‘needs a drink to sleep’ and becomes shaky, anxious, and sweaty if he misses his usual evening drinks. He has never been hospitalised for alcohol-related problems and has no known liver disease. He agrees to get help but is unsure how to stop.

Medications: Aspirin 100 mg daily, atorvastatin 20 mg nocte

Past history: Hypertension, ischaemic heart disease (stented 5 years ago), dyslipidaemia

Social history: Lives alone, widowed, limited social contact other than his daughter, no smoking or other drug use

Examination findings: BP 122/70 mmHg, HR 82 bpm, fine tremor of hands, mildly unsteady gait, short-term memory impairment, oriented to person and place only

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

Layla Morris, aged 33, presents for follow-up after a recent miscarriage at 10 weeks’ gestation. She reports feeling emotionally overwhelmed and has been drinking heavily since the loss — 1–2 bottles of wine most evenings. She denies prior problematic alcohol use but says this has become her main way of coping. She sleeps poorly, has stopped attending work, and reports daily crying and low mood. She denies suicidal ideation but says she feels ’empty and stuck’. She is open to getting help but is unsure where to start.

Medications: Nil

Past history: No formal mental health diagnoses, no previous pregnancies, no chronic illnesses

Social history: Lives with partner, works in admin (currently on leave), no smoking or drug use

Examination findings: Appears tearful, BP 118/76 mmHg, HR 78 bpm, no signs of intoxication, no tremor or withdrawal signs

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

Isaac Bell, aged 42, presents after experiencing chest tightness and shortness of breath during a run. He is a recreational bodybuilder and uses multiple performance-enhancing substances including testosterone, trenbolone, and human growth hormone (HGH) obtained online. He started using anabolic steroids 18 months ago and reports ‘cycling’ on and off every few months. He denies injecting heroin or other illicit drugs. He admits to mood swings, low libido during off cycles, and concerns about infertility. He has not disclosed this to previous doctors, fearing judgment.

Medications: Self-injected testosterone enanthate, trenbolone, oral HGH (non-prescribed)

Past history: Nil chronic illness, no known cardiovascular disease, non-smoker

Social history: Lives with partner, works as a personal trainer, alcohol socially, no recreational drug use

Examination findings: BP 152/96 mmHg, HR 88 bpm, muscular build, acne, mild gynaecomastia, normal heart and lung sounds

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

Hannah Greenwood, aged 36, presents seeking help to stop using prescription opioids. She was initially prescribed oxycodone after a car accident three years ago and continued using it for ongoing neck pain. Her previous GP retired, and she has been sourcing medications online and from friends. She takes 40–60 mg of oxycodone daily and reports morning withdrawal symptoms including sweating, muscle cramps, and anxiety. She says she wants to stop but feels frightened by the idea of withdrawal. She has two young children and is worried about her ability to function during the process.

Medications: Oxycodone (non-prescribed, daily use)

Past history: Whiplash injury, chronic neck pain, no formal mental health diagnoses

Social history: Lives with partner and children, previously employed (currently on leave), no smoking or alcohol use

Examination findings: BP 130/84 mmHg, HR 90 bpm, appears anxious, no focal neurological signs, pupils normal

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

Mohammed Farah, aged 50, presents for a new patient consultation. He has recently migrated to Australia and reports persistent insomnia and fatigue. When asked about medications, he discloses long-term use of over-the-counter sleeping pills purchased overseas that contain phenobarbital. He has been taking them nightly for over 10 years. Since arriving in Australia three weeks ago, he has run out of his supply and now feels agitated, shaky, and unable to sleep. He denies alcohol or illicit drug use. He appears anxious about discussing his medication use and asks if he can get the same tablets locally.

Medications: Previously self-administered phenobarbital-containing OTC sleeping pills (no longer available)

Past history: Nil formal diagnoses, no hospitalisations

Social history: Recently arrived refugee, lives with extended family, no current income, fluent in English

Examination findings: BP 140/88 mmHg, HR 96 bpm, mild tremor, anxious affect, alert and oriented

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

Jessica Wong, aged 30, presents for follow-up after recently being diagnosed with binge eating disorder. During the consultation, she discloses that she frequently uses over-the-counter laxatives (senna and bisacodyl) to ‘control her weight’ after binge episodes. She reports using up to 10–15 tablets at a time, several times per week, and has done so for over a year. She says she feels ‘addicted to the cycle’ and becomes very anxious if she does not have laxatives on hand. She is otherwise physically well and denies self-induced vomiting, diuretic use, or illicit drug use.

Medications: Nil

Past history: Binge eating disorder (recent diagnosis), no other chronic conditions

Social history: Lives alone, works in retail, no alcohol or tobacco use

Examination findings: BP 106/70 mmHg, HR 88 bpm, BMI 21, dry mucous membranes, no oedema

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

Reuben Haines, aged 59, presents after experiencing a syncopal episode while gardening. He reports feeling lightheaded for several weeks and has lost about 6 kg unintentionally. On questioning, he discloses consuming at least 2 litres of cola daily for over 10 years and eating minimal solid food. He attributes this habit to chronic stress and describes strong cravings and ‘withdrawal headaches’ if he doesn’t drink cola. He denies alcohol or illicit drug use. He is otherwise independent and has not seen a GP in years.

Medications: Nil

Past history: Nil known chronic illness, no medications

Social history: Lives alone, retired, poor diet, sedentary lifestyle

Examination findings: BP 102/66 mmHg, HR 98 bpm, dry mucous membranes, BMI 17, appears anxious and undernourished

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

Olivia Russo, aged 25, presents for a mental health care plan. She discloses daily use of vaping devices containing THC oil, which she began 12 months ago to help with sleep and anxiety. She sources the oil online and vapes several times per day, including immediately upon waking. She says she feels ‘foggy’ in the mornings, has difficulty concentrating, and feels anxious without it. She denies using cannabis flower, tobacco, or alcohol. She reports previous unsuccessful attempts to stop vaping due to insomnia and irritability. She is seeking support to quit but is unsure where to begin.

Medications: Nil

Past history: Generalised anxiety disorder (self-reported, no previous formal diagnosis or treatment)

Social history: Lives with housemates, part-time student, casual retail work

Examination findings: Vitals normal, BMI 22, no overt signs of intoxication, anxious affect

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

Daniel Brody, aged 46, presents for follow-up after being discharged from hospital following a non-fatal opioid overdose. He was found unconscious at home by a friend and revived by ambulance officers with intranasal naloxone. He has a 15-year history of heroin use but had recently been injecting fentanyl sourced online, which he believed was ‘heroin’. He is frightened by the experience and states he wants help to stop using but feels ashamed and unsure where to start. He is not currently on any opioid pharmacotherapy and has not engaged with AOD services previously.

Medications: Nil

Past history: IV drug use (heroin, fentanyl), hepatitis C (treated 4 years ago), recurrent abscesses

Social history: Lives in temporary housing, unemployed, limited family contact, no alcohol use

Examination findings: BP 118/76 mmHg, HR 80 bpm, injection marks on forearms, appears subdued and anxious

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

Nina Watts, aged 31, presents for contraception advice. During the consultation, she discloses that she recently stopped using methamphetamine after years of regular use, including injecting. She reports being ‘clean’ for the past 3 months and attending weekly counselling at a local AOD service. She now wants to focus on her health, including contraception and planning for future pregnancy. She is concerned about whether her drug use has caused long-term harm to her fertility or general health. She has irregular periods and is not using any contraception currently.

Medications: Nil

Past history: Methamphetamine dependence (now in remission), no known STIs, no chronic illness

Social history: Lives with partner, stable housing, no current substance use, no smoking or alcohol

Examination findings: Vitals normal, BMI 24, no signs of injection site infection, speculum and bimanual exam normal

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

Trent Dawson, aged 38, presents requesting help with managing chronic insomnia. He reports using over-the-counter sedating antihistamines (diphenhydramine and doxylamine) nightly for the past 2 years. He takes increasing doses, often combining products, and reports next-day drowsiness and poor memory. He has tried herbal remedies and meditation without success. He denies alcohol or other drug use but says he feels ‘stuck’ and cannot sleep without the pills. He works as a truck driver and is concerned about his alertness on the road.

Medications: OTC sedating antihistamines (self-administered)

Past history: None significant

Social history: Works full-time, lives with partner, no alcohol or recreational drugs

Examination findings: Vitals normal, BMI 26, no focal neurological findings, appears tired

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

Emily Nadar, aged 29, presents with her partner for support with quitting smoking. She has smoked since age 17 and currently smokes about 15 cigarettes per day. She reports several prior quit attempts using patches and gum but relapsed each time during periods of stress. She has never used prescription pharmacotherapy. She is now 8 weeks pregnant and motivated to quit but says she feels overwhelmed by cravings and is worried about harming the baby. She reports mild morning nausea but is otherwise well. Her partner also smokes, though less frequently.

Medications: Prenatal vitamins

Past history: None significant

Social history: Lives with partner, works full time, no alcohol or other drug use

Examination findings: BP 114/72 mmHg, HR 82 bpm, non-febrile, normal BMI, no respiratory findings

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

Caleb Thomson, aged 44, presents requesting help with quitting alcohol. He drinks approximately 10 standard drinks daily, mostly beer and wine, and has done so for over a decade. He reports early morning drinking to relieve tremors and states he feels physically ill when trying to cut back. He has never had a seizure or been hospitalised for withdrawal. He works part-time and lives alone. He has no history of illicit drug use. He is motivated to stop drinking but is concerned about withdrawal symptoms and whether he can manage it at home.

Medications: Nil

Past history: Hypertension (controlled with diet), depression (untreated), no liver disease known

Social history: Lives alone, no smoking, employed part-time in landscaping

Examination findings: BP 140/84 mmHg, HR 94 bpm, fine tremor in hands, mild diaphoresis, no jaundice or stigmata of chronic liver disease

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

Yasmin Ahmed, aged 34, presents seeking advice about her use of over-the-counter codeine-containing cough syrup. She began using it for a persistent cough over a year ago, but continued taking it nightly to help with anxiety and sleep. She now uses one bottle every 2–3 days and becomes anxious, restless, and has gastrointestinal discomfort when trying to stop. She has not disclosed this to any other healthcare provider and is distressed about the potential harm to her health. She is otherwise physically well and reports no other substance use.

Medications: Codeine-based cough syrup (OTC, self-administered)

Past history: Anxiety (self-managed), nil other diagnoses

Social history: Lives with flatmates, works part-time in retail, no alcohol or tobacco use

Examination findings: Vitals normal, BMI 23, mildly anxious, no signs of intoxication or withdrawal, no upper respiratory symptoms

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