KFP – Integrative medicine

Trent Gallagher, aged 58, presents to your general practice clinic with ongoing fatigue, musculoskeletal aches, and low mood. He has had extensive investigations over the past 12 months with no significant abnormalities identified. He was previously diagnosed with mild depression but declined antidepressants, preferring to try alternative approaches. He works part-time as a landscaper and is concerned about staying fit and active. He has recently started seeing a naturopath and taking a variety of supplements including magnesium, St John’s Wort, and a proprietary herbal ‘energy tonic’. He asks for your opinion on these treatments and whether any investigations or referrals might help him.

Medications: Herbal tonic (contents unclear), St John’s Wort, magnesium powder, occasional ibuprofen

Allergies: Nil known

Past history: Mild depression (diagnosed 12 months ago), low vitamin D (corrected), mechanical back pain

Social history: Lives with partner, non-smoker, drinks 1–2 glasses of wine on weekends, walks daily

Preventative Healthcare: Cardiovascular risk assessment done 6 months ago – low risk, no recent mental health care plan

Examination findings: Vitals normal. No clinical signs of systemic illness. Mild tenderness over paraspinal lumbar muscles. No neurological deficits.

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

Emily Barbour, aged 34, presents to discuss fertility and menstrual regulation. She and her partner have been trying to conceive for 18 months. She has regular but heavy and painful periods, and her recent transvaginal ultrasound showed a normal uterus and ovaries. She works as a yoga instructor and reports high stress levels over the past year. Emily says she’s been seeing a Traditional Chinese Medicine (TCM) practitioner who has recommended acupuncture and various herbal remedies to ‘rebalance her hormones’. She requests your advice about these therapies and asks if anything else could be done to optimise her fertility.

Medications: Vitex (chasteberry), evening primrose oil, multi-vitamin with folic acid

Allergies: Nil known

Past history: Appendectomy age 17, no chronic illnesses

Social history: Non-smoker, vegetarian diet, regular exercise, moderate alcohol (2–3 glasses/week)

Investigations: Day 21 serum progesterone: 32 nmol/L (ref >25 indicates ovulation), partner’s semen analysis: normal

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

Nathan Reyes, aged 47, presents for a general check-up. He has a family history of bowel cancer and hypertension. Over the past six months, he has been following a ‘detox’ regime advised by a social media health influencer, which includes intermittent fasting, infrared sauna use, and a variety of herbal ‘cleansing’ teas. He has also started taking activated charcoal supplements and reports cutting out gluten and dairy, despite no specific symptoms suggestive of intolerance. He reports improved energy and ‘mental clarity’ but is concerned after a recent article warned of potential kidney damage from detox products. He asks whether he should continue with his regime and whether further testing is needed.

Medications: Herbal teas (ingredients include dandelion root, senna, licorice), activated charcoal capsules

Allergies: Nil known

Past history: Nil significant medical history

Family history: Father with bowel cancer at age 59, mother with hypertension

Social history: Works as a freelance graphic designer, non-smoker, drinks alcohol occasionally, no regular exercise

Examination findings: BP 138/90, HR 68, BMI 27. No abnormalities on physical examination.

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

Amira Siddiqui, a 26-year-old postgraduate student, presents to your practice with worsening anxiety, poor sleep, and fatigue. She has a history of generalised anxiety disorder and has previously attended cognitive behavioural therapy, which she found helpful. She discontinued therapy six months ago due to cost and scheduling conflicts. Amira is reluctant to take pharmacological treatments and says she has been researching ‘natural anxiety remedies’. She has recently started self-administering high-dose ashwagandha, lavender oil capsules, and melatonin purchased online from overseas. She meditates daily and has recently begun attending sound healing sessions. She wants to know whether these therapies are safe and if there are other ways to manage her symptoms holistically.

Medications: Ashwagandha 1200 mg daily, lavender oil capsules, melatonin 10 mg nocte

Allergies: Nil known

Past history: Generalised anxiety disorder, no history of major depression or psychosis

Social history: Lives alone, no drug use, drinks socially, pescatarian diet, regular yoga and meditation practice

Examination findings: BMI 21.5, vitals normal, no signs of physical illness, PHQ-9 score: 10, GAD-7 score: 14

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

Helen MacIntyre, a 72-year-old retired teacher, presents with chronic knee pain due to osteoarthritis. She has been trialling various non-pharmacological approaches including turmeric capsules, fish oil, and topical arnica cream, with limited improvement. She is hesitant about using regular NSAIDs due to a history of mild gastritis and is not interested in surgery. Helen also recently commenced tai chi at her local community centre and is considering visiting a chiropractor who offers ‘joint detox’ sessions. She asks what other options she can try to manage her knee pain naturally and whether she should proceed with chiropractic treatment.

Medications: PRN paracetamol, turmeric 1.2g/day, fish oil capsules, arnica cream

Allergies: Nil known

Past history: Osteoarthritis (bilateral knees), gastritis (resolved), hypertension (well controlled)

Social history: Widowed, lives independently, active in local community garden and seniors’ group

Examination findings: Vitals normal, BMI 25.6, knees with mild effusion, crepitus, and limited flexion but no instability

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

Peter Zhong, aged 54, presents with poorly controlled type 2 diabetes. His HbA1c is 8.9% despite being on metformin and gliclazide. He expresses frustration and says he wants to take a more ‘natural’ approach to his diabetes. Peter recently attended a community seminar on ‘reversing diabetes through natural medicine’ and has started taking cinnamon capsules, berberine extract, and bitter melon tea. He has also cut out all grains and dairy, and is intermittently fasting for 18 hours a day. He requests your input on his current approach and what else he could be doing to manage his diabetes more naturally.

Medications: Metformin XR 1g daily, gliclazide MR 60 mg daily, cinnamon capsules, berberine, bitter melon tea

Allergies: Nil known

Past history: Type 2 diabetes (diagnosed 4 years ago), hypercholesterolaemia, overweight (BMI 29.4)

Family history: Father had T2DM and died from myocardial infarction at 62

Social history: Works in IT, sedentary lifestyle, lives with partner, recently joined online diabetes reversal group

Investigations: HbA1c 8.9%, eGFR 80, ALT 32, fasting lipids: TC 5.3, LDL 3.1, HDL 1.1, TG 2.0

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

James O’Donnell, a 41-year-old marketing executive, presents for follow-up regarding irritable bowel syndrome (IBS). He reports fluctuating symptoms of bloating, intermittent abdominal cramping, and alternating diarrhoea and constipation. He has undergone previous investigations including colonoscopy and coeliac serology, which were normal. James has tried a low FODMAP diet with partial success and is now interested in exploring probiotics, gut-directed hypnotherapy, and Ayurvedic treatments he has read about online. He is not currently taking any prescribed medications but is using turmeric capsules and triphala, an Ayurvedic bowel tonic. He asks for your advice on the role of natural therapies and what else he can try to improve symptoms.

Medications: Turmeric capsules, triphala powder

Allergies: Nil known

Past history: IBS diagnosed 2 years ago, anxiety managed with CBT

Social history: Lives with partner, high-stress job, regular gym-goer, pescatarian diet

Investigations: Normal colonoscopy (12 months ago), negative coeliac serology, normal full blood count, CRP, and thyroid function

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

Deborah Lyons, a 63-year-old retired nurse, presents seeking advice on managing menopausal symptoms without hormone replacement therapy (HRT). She reports ongoing hot flushes, night sweats, poor sleep, and vaginal dryness that are affecting her quality of life. Deborah has a past history of oestrogen-receptor positive breast cancer treated with surgery and tamoxifen five years ago. She is now in remission. She recently attended a women’s wellness seminar and has started using black cohosh, evening primrose oil, and red clover supplements. She also attends a weekly yoga class and uses a meditation app. Deborah is asking if her current supplements are safe and if there are other natural options she could consider.

Medications: Calcium with vitamin D, black cohosh, evening primrose oil, red clover extract

Allergies: Nil known

Past history: ER+ breast cancer (treated 5 years ago), hypertension (controlled)

Family history: Mother had osteoporosis, father had ischaemic heart disease

Social history: Widowed, non-smoker, drinks wine occasionally, eats a Mediterranean-style diet

Examination findings: BP 124/78, BMI 24. No concerning physical findings. Mammogram 6 months ago was normal.

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

Michael Tran, a 35-year-old secondary school teacher, presents seeking help with ongoing insomnia and fatigue. His difficulties sleeping began over a year ago after a stressful work period. He reports difficulty falling asleep and frequent nocturnal awakenings. He often lies awake thinking about work and wakes feeling unrefreshed. He avoids caffeine after midday, limits alcohol, and has trialled melatonin (3 mg) and valerian root extract with minimal effect. He is interested in further natural options and has recently enrolled in an online course on sleep optimisation using light therapy and herbal nootropics. He asks about the safety and efficacy of these options, and whether he should pursue formal sleep studies.

Medications: OTC melatonin 3 mg nocte, valerian root capsules, magnesium powder

Allergies: Nil known

Past history: None significant. No current or past psychiatric diagnosis

Social history: Lives with partner, high screen time use in evenings, moderate alcohol intake, exercises occasionally

Examination findings: Normal vitals, BMI 23. No signs of obstructive sleep apnoea. Mood and affect appropriate. Epworth Sleepiness Scale score: 8

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

Angela Kouris, a 48-year-old naturopath, presents for a consultation to discuss her management of newly diagnosed mild hypertension. She was recently diagnosed after three elevated readings over two months, with an average home BP of 144/92 mmHg. Angela is otherwise well and prefers to avoid pharmaceutical treatment if possible. She is currently trialling dietary approaches including increased garlic, celery juice, and hibiscus tea. She takes magnesium, coenzyme Q10, and omega-3 supplements. She has also resumed a daily meditation practice and walks five days a week. Angela asks for your opinion on these measures and whether it’s safe to delay starting antihypertensive medication.

Medications: Magnesium glycinate, CoQ10, omega-3 fish oil, garlic capsules, hibiscus tea

Allergies: Nil known

Past history: Nil significant

Family history: Father had hypertension and myocardial infarction at age 60

Social history: Non-smoker, no alcohol, vegetarian, runs a wellness clinic

Examination findings: BP 146/90, BMI 22.8, normal heart and lung exam, no end-organ damage on fundoscopy or urinalysis

Investigations: UEC, lipids, HbA1c all within normal limits

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

Fatima Alvi, a 29-year-old university student, presents with frequent migraines. She has had episodic migraines since her teenage years, but they have become more frequent—now occurring weekly with associated photophobia and nausea. She takes sumatriptan as needed and has trialled propranolol in the past but stopped due to fatigue. Fatima prefers not to use daily medications and has started using riboflavin (vitamin B2), magnesium supplements, and butterbur extract based on her own research. She also sees an acupuncturist fortnightly. She asks your opinion on these therapies and what else she can do to reduce her migraine frequency.

Medications: PRN sumatriptan, magnesium citrate, riboflavin 400 mg daily, butterbur extract (brand not TGA-listed)

Allergies: Nil known

Past history: Migraine with aura, no other medical conditions

Family history: Mother also has migraines

Social history: Lives in student accommodation, drinks socially, non-smoker, moderate stress, irregular sleep patterns

Examination findings: Neurological examination normal, BMI 21. Visual acuity normal. No red flags on history.

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

Rosalie Ng, a 67-year-old retired pharmacist, presents to discuss options for managing her osteopenia. A recent DEXA scan showed a T-score of -2.1 at the femoral neck. She has no history of fractures but is concerned due to her mother’s hip fracture at age 74. Rosalie prefers to avoid bisphosphonates at this stage and is taking calcium, vitamin D, and a powdered collagen supplement. She recently started taking a traditional Chinese medicine (TCM) formula containing deer antler and various herbs, which she obtained from an overseas practitioner. She asks whether these therapies are safe and effective, and what else she can do to reduce her fracture risk.

Medications: Calcium carbonate with vitamin D3, marine collagen powder, TCM bone formula (contents partially labelled in Chinese)

Allergies: Nil known

Past history: Hypertension (well controlled), mild osteoarthritis

Family history: Mother had osteoporotic hip fracture, father had hypertension

Social history: Lives independently, walks daily, pescatarian diet, drinks wine occasionally

Examination findings: Height 160 cm (down 2 cm from age 60), weight 60 kg, BP 128/78. No kyphosis or tenderness on spinal palpation

Investigations: DEXA: femoral neck T-score -2.1, lumbar spine T-score -1.9. eGFR 72, normal calcium, phosphate, and thyroid function

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

Levi Walters, a 45-year-old software engineer, presents to discuss chronic low back pain. The pain has persisted for over a year and is localised to the lower lumbar region without radiation. It is worse with prolonged sitting and improves with movement. He has had plain lumbar X-rays, which show mild degenerative changes. Physiotherapy and analgesia (paracetamol and occasional ibuprofen) have provided limited benefit. Levi is interested in a more holistic approach and has started seeing a myotherapist and receiving dry needling therapy. He also began a trial of CBD oil obtained online, which he finds mildly helpful but is unsure about its legality and safety. He asks whether he should continue, and what else he could try.

Medications: PRN paracetamol, ibuprofen, CBD oil (not prescribed, self-sourced online)

Allergies: Nil known

Past history: Chronic mechanical lower back pain

Social history: Works from home, sedentary lifestyle, ex-smoker, drinks beer on weekends

Examination findings: BMI 28, lumbar tenderness, reduced range of motion in flexion, no neurological deficits or red flags

Investigations: Lumbar spine X-ray: mild disc space narrowing at L4/L5, no red flag features

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

Yasmine Farah, a 38-year-old primary school teacher, presents for advice on managing polycystic ovary syndrome (PCOS) using natural therapies. She was diagnosed 5 years ago based on irregular cycles and polycystic ovaries on ultrasound. She is not currently trying to conceive but is concerned about weight gain, hirsutism, and fatigue. She has declined oral contraceptives and metformin in the past due to side effect concerns. Yasmine is now taking inositol powder, spearmint tea, and berberine capsules purchased online. She is also seeing a naturopath and following a gluten- and dairy-free diet. She asks what else she can do and whether her current regimen is safe.

Medications: Inositol 2g BID, berberine 500 mg TID, spearmint tea daily

Allergies: Nil known

Past history: PCOS (diagnosed age 33), mild acne

Family history: Mother with type 2 diabetes, sister with PCOS

Social history: Lives with partner, BMI 31, sedentary occupation, follows naturopathic dietary advice

Examination findings: BP 126/84, waist circumference 95 cm, mild facial hirsutism, no acanthosis nigricans, no goitre

Investigations: Fasting insulin 22 (H), total testosterone mildly elevated, HbA1c 5.8%, pelvic US: polycystic ovaries bilaterally

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

Thomas Duong, a 62-year-old retired engineer, presents to discuss strategies for managing mild cognitive impairment (MCI). He has noticed increasing forgetfulness over the past year, including difficulty recalling names and recent events. His MoCA score is 25/30, and neurological exam is unremarkable. His GP has diagnosed MCI and ruled out reversible causes. Thomas is motivated to support his cognition naturally and has started taking ginkgo biloba, curcumin, and a ‘nootropic brain support’ supplement purchased online. He also plays Sudoku daily, has begun mindfulness meditation, and is considering a ketogenic diet. He asks for advice on the safety and utility of his current strategies.

Medications: Ginkgo biloba 120 mg BID, curcumin capsules, proprietary nootropic blend (contains bacopa, alpha-GPC, and unknown proprietary ingredients)

Allergies: Nil known

Past history: Hypertension (controlled), dyslipidaemia

Family history: Mother had Alzheimer’s disease, diagnosed in her 70s

Social history: Non-smoker, drinks red wine occasionally, regular exercise, Mediterranean-style diet

Investigations: Normal FBC, TSH, B12, folate, CT brain: age-appropriate changes

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

Sophia Lemaire, a 52-year-old yoga instructor, presents to discuss ongoing symptoms of perimenopause. She experiences irregular periods, mood swings, fatigue, and frequent night sweats. She has no significant medical history and prefers a natural approach to her symptoms. She has been using a combination of herbal products including maca root, black cohosh, and chaste tree (vitex). She also takes magnesium and evening primrose oil. Sophia reports some mild improvement but continues to feel ‘off balance’ emotionally and physically. She asks what else she can try and whether her current approach is safe and evidence-based.

Medications: Black cohosh, maca root powder, vitex, evening primrose oil, magnesium glycinate

Allergies: Nil known

Past history: Nil significant. No history of breast cancer or thromboembolic disease

Family history: Mother had osteoporosis, father had type 2 diabetes

Social history: Non-smoker, minimal alcohol, vegetarian, teaches yoga full-time

Examination findings: BP 118/74, BMI 22, no abnormal findings

Investigations: FSH 42 IU/L, oestradiol low-normal, TSH normal. Mammogram and cervical screening up to date

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

Jonathan Marks, a 50-year-old accountant, presents to discuss integrative approaches to managing irritable bowel syndrome (IBS). He has a longstanding history of IBS with predominant diarrhoea (IBS-D). Colonoscopy 2 years ago was normal, and coeliac disease was excluded. He has trialled antispasmodics and a low FODMAP diet with some benefit. Jonathan is now interested in complementary therapies. He has started taking peppermint oil capsules and is considering hypnotherapy and Ayurvedic treatments. He recently began using triphala (an Ayurvedic bowel tonic) and turmeric capsules sourced from overseas. He wants your opinion on the safety and utility of these approaches and whether further tests are needed.

Medications: Peppermint oil capsules, turmeric capsules, triphala powder

Allergies: Nil known

Past history: IBS-D diagnosed 6 years ago, no alarm features

Family history: Non-contributory

Social history: Works full-time, moderate stress, non-smoker, occasional alcohol, pescatarian

Examination findings: Normal BMI, soft non-tender abdomen, no red flags

Investigations: Normal FBC, CRP, coeliac screen, TSH. Colonoscopy 2 years ago: macroscopically and histologically normal

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

Jillian Reid, a 44-year-old marketing executive, presents seeking support for chronic fatigue. She reports ongoing tiredness for more than 12 months, unrelieved by sleep. She describes ‘brain fog’, unrefreshing rest, and difficulty concentrating. Extensive prior investigations including FBC, iron studies, thyroid function, and autoimmune screening have been normal. She meets the criteria for chronic fatigue syndrome (CFS). Jillian has been trialling naturopathic treatments including intravenous vitamin infusions, adrenal support supplements (containing licorice, ginseng, and ashwagandha), and a strict paleo diet. She also takes high-dose vitamin C and B12 intramuscularly every fortnight at a private clinic. She asks for your input on her current therapies and whether anything else can help her feel better.

Medications: OTC adrenal supplements, vitamin C 3 g/day, IM vitamin B12 fortnightly, ashwagandha capsules

Allergies: Nil known

Past history: Diagnosed CFS/ME 6 months ago, mild anxiety

Family history: Sister has hypothyroidism

Social history: Lives alone, reduced work hours due to fatigue, avoids caffeine and alcohol

Examination findings: Vitals normal, BMI 23, appears tired but not distressed. No lymphadenopathy or muscle tenderness

Investigations: All recent tests including CBC, TFTs, CRP, vitamin D, B12, ferritin, coeliac screen: within normal limits

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

Kylie Hartman, a 36-year-old woman, presents to discuss integrative approaches to managing endometriosis. She was diagnosed laparoscopically 2 years ago and experiences pelvic pain, dysmenorrhoea, and fatigue. She is not currently planning pregnancy. Kylie previously tried the combined oral contraceptive pill, which improved symptoms but caused mood changes, leading her to discontinue. She is now taking turmeric, omega-3 fish oil, and a TCM formula obtained from an online herbalist. She also follows a gluten-free, anti-inflammatory diet and attends acupuncture weekly. She reports moderate symptom improvement and asks for your opinion on the safety and effectiveness of her current approach, and whether she should restart hormonal therapy.

Medications: Turmeric capsules, omega-3 fish oil, Traditional Chinese Medicine (TCM) herbal blend (ingredients unlabelled), PRN paracetamol

Allergies: Nil known

Past history: Endometriosis (stage 2, laparoscopically confirmed), mild anxiety

Family history: Sister with endometriosis, mother with depression

Social history: Works full-time, non-smoker, occasional alcohol, vegetarian diet

Examination findings: BMI 21, mild lower abdominal tenderness, no palpable masses

Investigations: Recent pelvic ultrasound: no ovarian endometriomas or adnexal masses

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

Benjamin Tan, a 40-year-old software developer, presents seeking advice on managing generalised anxiety using integrative approaches. He was diagnosed with generalised anxiety disorder (GAD) 2 years ago and has previously attended cognitive behavioural therapy (CBT), which he found helpful but discontinued due to cost. He is reluctant to start SSRIs due to fear of side effects. Benjamin is currently using L-theanine, passionflower extract, and magnesium supplements. He also practises daily mindfulness and has enrolled in a weekly breathwork class. He asks whether these therapies are effective and what else he could consider that aligns with his preference for natural management.

Medications: L-theanine 200 mg BID, passionflower capsules, magnesium glycinate

Allergies: Nil known

Past history: GAD, mild insomnia

Family history: Father has GAD, mother has depression

Social history: Lives alone, works remotely, pescatarian diet, drinks alcohol socially, exercises irregularly

Examination findings: Vitals normal, BMI 24, PHQ-9: 6, GAD-7: 13. No signs of major depression or psychosis

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

Amelia Cross, a 58-year-old primary school teacher, presents seeking support for chronic joint pain. She has been diagnosed with seronegative rheumatoid arthritis (RA) and is managed by a rheumatologist with hydroxychloroquine and intermittent NSAIDs. Amelia is concerned about medication side effects and is keen to explore natural anti-inflammatory options. She has started taking boswellia, turmeric, and a plant-based omega-3 supplement. She also follows an anti-inflammatory diet and does weekly tai chi. She reports mild improvement in stiffness and overall wellbeing. Amelia asks whether these approaches are evidence-based and if she can reduce her conventional medication dose.

Medications: Hydroxychloroquine 200 mg BID, fish oil (algae-derived), turmeric capsules, boswellia extract

Allergies: Nil known

Past history: Seronegative RA (diagnosed 3 years ago), hypertension

Family history: Father with osteoarthritis, mother with coeliac disease

Social history: Lives with husband, vegetarian diet, walks regularly, no smoking or alcohol use

Examination findings: Mild swelling of MCP and PIP joints bilaterally, morning stiffness improving over 30 minutes

Investigations: Recent CRP 5.2 (normal), ESR 18 mm/hr, normal renal and liver function, ANA and RF negative

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

Nathan Wallace, a 33-year-old landscaper, presents seeking support for ongoing eczema that has not responded well to topical corticosteroids alone. He experiences persistent pruritus, particularly on his flexures and neck, and has frequent flares triggered by stress and seasonal changes. Nathan recently started using a variety of complementary treatments including evening primrose oil, probiotics, and a traditional Chinese herbal cream sourced online. He also follows a gluten-free, dairy-free diet based on advice from a naturopath. He reports partial improvement but is concerned about the safety of the herbal cream and asks whether he should continue with this approach.

Medications: Topical betamethasone valerate, antihistamines PRN, evening primrose oil, probiotic supplement, Chinese herbal cream (labelled in Mandarin)

Allergies: Nil known

Past history: Atopic dermatitis since childhood, hay fever

Family history: Mother with eczema and asthma

Social history: Works outdoors, lives with partner, non-smoker, no regular alcohol

Examination findings: Erythematous lichenified patches in antecubital fossae and neck, excoriations present, no signs of secondary infection

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

Ella Papadopoulos, a 27-year-old barista, presents seeking advice on managing dysmenorrhoea and premenstrual mood symptoms using natural therapies. Her periods are regular but painful, and she experiences irritability, breast tenderness, and fatigue in the week prior to menstruation. She prefers to avoid hormonal contraception and is not currently sexually active. Ella has been self-managing with chasteberry (vitex), magnesium supplements, and ginger tea. She also uses a period tracking app and practices yoga regularly. She reports mild benefit but wants to know what else she can try, and whether her current approach is supported by evidence.

Medications: Vitex agnus-castus extract, magnesium citrate, ginger tea

Allergies: Nil known

Past history: Primary dysmenorrhoea, PMS

Family history: Mother had similar symptoms, no history of endometriosis

Social history: Non-smoker, minimal alcohol, pescatarian diet, no recent travel

Examination findings: Vitals normal, BMI 21. No abdominal or pelvic masses, mild lower abdominal tenderness reported

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

Daniel Nguyen, a 49-year-old civil engineer, presents seeking support for managing elevated cholesterol using natural therapies. He has a recent fasting lipid profile showing total cholesterol of 6.2 mmol/L, LDL 4.0 mmol/L, HDL 1.1 mmol/L, and triglycerides 1.8 mmol/L. He is otherwise well, with no history of cardiovascular disease, diabetes, or smoking. His blood pressure is stable and BMI is 25.5. Daniel prefers to avoid statins at this stage and has started using red yeast rice, plant sterol-enriched margarine, and a fibre supplement. He follows a pescatarian Mediterranean-style diet and exercises 3–4 times per week. He asks for your thoughts on his current regimen and whether it is safe and sufficient.

Medications: Red yeast rice capsules (monacolin K 10 mg), psyllium husk, plant sterol-enriched spread

Allergies: Nil known

Past history: Mild hypercholesterolaemia

Family history: Father had myocardial infarction at age 61, mother has hypertension

Social history: Non-smoker, drinks wine occasionally, active lifestyle

Examination findings: BP 122/76, waist circumference 94 cm, cardiovascular and abdominal exams normal

Investigations: Fasting lipids as above, HbA1c 5.3%, eGFR 88, LFTs normal

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

Layla Hassan, a 42-year-old physiotherapist, presents for support managing chronic insomnia using natural methods. She reports taking over 45 minutes to fall asleep and waking multiple times during the night. This has been ongoing for over 8 months and is starting to affect her concentration at work. Layla is reluctant to take sleeping tablets or antidepressants. She currently uses valerian root capsules, melatonin (2 mg slow-release), and practices guided meditation nightly. She has also been using a lavender essential oil diffuser and avoiding screens for an hour before bed. Layla asks whether her current therapies are appropriate and what else she might consider.

Medications: Melatonin 2 mg SR, valerian extract, magnesium glycinate, lavender oil diffuser

Allergies: Nil known

Past history: Chronic insomnia, mild generalised anxiety (no formal diagnosis)

Family history: Mother with depression, father with sleep apnoea

Social history: Lives with partner, drinks herbal tea in the evening, pescatarian diet, non-smoker

Examination findings: Vitals normal, BMI 23, no signs of sleep apnoea. Epworth Sleepiness Scale score: 6

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

Arjun Mehta, a 34-year-old accountant, presents to discuss managing recurrent functional gastrointestinal symptoms with natural therapies. He reports intermittent bloating, abdominal discomfort, and loose stools that worsen with stress. He was previously diagnosed with irritable bowel syndrome (IBS-D) after normal investigations including colonoscopy and coeliac screening. He has since tried a low FODMAP diet with partial success. Arjun now uses peppermint oil capsules, drinks chamomile tea daily, and takes a multi-strain probiotic. He recently began exploring Ayurvedic medicine and is using a herbal blend containing ashwagandha, licorice root, and triphala. He asks whether these options are effective and safe to continue long term.

Medications: Peppermint oil, probiotic, Ayurvedic herbal blend (including ashwagandha, licorice, triphala), chamomile tea

Allergies: Nil known

Past history: IBS-D, stress-related insomnia

Family history: Non-contributory

Social history: Works long hours, high stress, pescatarian diet, non-smoker, no alcohol

Examination findings: Normal vitals, BMI 22. Abdominal exam: soft, non-tender, no organomegaly

Investigations: Recent FBC, CRP, TFTs, coeliac serology all normal. Colonoscopy 18 months ago: normal

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

Freya Mitchell, a 61-year-old retired yoga teacher, presents for advice on managing osteoarthritis of the knees. She has bilateral knee pain that worsens with activity and has been diagnosed radiologically with moderate osteoarthritis. Freya prefers to avoid NSAIDs due to a history of gastritis and is not keen on intra-articular steroid injections. She takes glucosamine, chondroitin, turmeric, and a collagen supplement. She also practises yoga and uses warm compresses regularly. She asks whether her supplements are worthwhile and what else she can try to reduce pain and maintain function naturally.

Medications: Glucosamine sulfate, chondroitin, turmeric capsules, hydrolysed collagen powder

Allergies: Nil known

Past history: Gastritis, hypertension

Family history: Mother had osteoarthritis, father had hypertension

Social history: Non-smoker, no alcohol, pescatarian, regular low-impact activity

Examination findings: BMI 24, mild bilateral knee crepitus, tenderness on palpation, no joint effusion or instability

Investigations: Knee X-rays: moderate medial joint space narrowing bilaterally, no erosions or effusion

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

Marcus Liu, a 38-year-old software developer, presents seeking support for managing mild to moderate psoriasis using natural and integrative approaches. He has well-demarcated, scaly plaques on his elbows, knees, and scalp, diagnosed 5 years ago. He has previously used topical corticosteroids intermittently, which helped but caused skin thinning. Marcus is now trying fish oil supplements, vitamin D drops, and a topical preparation containing aloe vera and turmeric. He also follows a Mediterranean-style diet and practises daily mindfulness. He asks whether these strategies are effective and if any further steps can be taken to optimise his management without returning to corticosteroids.

Medications: Fish oil (2000 mg/day), vitamin D3 (1000 IU/day), topical aloe vera with turmeric extract

Allergies: Nil known

Past history: Mild to moderate chronic plaque psoriasis, anxiety (well managed without medication)

Family history: Father with psoriasis and hypertension

Social history: Non-smoker, moderate alcohol intake, pescatarian diet, works from home

Examination findings: Well-demarcated plaques on elbows, knees, scalp. No joint tenderness or swelling. No nail pitting

Investigations: Vitamin D: 62 nmol/L, CRP normal, no signs of psoriatic arthritis

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

Isabella Moretti, a 30-year-old high school teacher, presents for preconception counselling. She and her partner plan to start trying for a pregnancy in the next few months. Isabella has no known fertility issues but is keen to optimise her health naturally. She currently takes a prenatal multivitamin and coenzyme Q10 and is interested in using acupuncture and traditional Chinese medicine (TCM) to ‘enhance fertility’. She also follows a Mediterranean diet and uses a fertility tracking app. She asks if her supplements and strategies are appropriate and whether additional tests or changes are needed.

Medications: Prenatal multivitamin with folic acid, CoQ10 200 mg/day

Allergies: Nil known

Past history: Nil significant

Family history: Mother had gestational diabetes

Social history: Non-smoker, occasional alcohol (ceased in preparation for conception), exercises regularly, pescatarian diet

Examination findings: Vitals normal, BMI 22, no signs of PCOS or endocrine dysfunction

Investigations: Not yet performed

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

Yousef Al-Khalil, a 55-year-old business owner, presents for follow-up after recent diagnosis of type 2 diabetes. He was diagnosed three months ago with a fasting glucose of 8.2 mmol/L and HbA1c of 7.2%. He has declined pharmacological therapy at this stage and wants to trial lifestyle and natural therapies. Yousef is currently following a low-carbohydrate Mediterranean diet, walking daily, and using cinnamon capsules, berberine, and fenugreek supplements. He asks whether these natural approaches are safe and effective, and what else he can do to avoid medication.

Medications: Cinnamon extract, berberine 500 mg BID, fenugreek seed capsules

Allergies: Nil known

Past history: Newly diagnosed T2DM, hypertension (on amlodipine)

Family history: Both parents with T2DM

Social history: Non-smoker, drinks wine occasionally, BMI 28, works long hours but walks daily

Examination findings: BP 130/80, waist circumference 100 cm, no peripheral neuropathy or retinal changes

Investigations: HbA1c 7.2%, fasting glucose 8.2 mmol/L, eGFR 90, LFTs normal, lipid profile: total cholesterol 5.1, HDL 1.0, LDL 3.2, triglycerides 1.8

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

Chloe Ramsay, a 47-year-old public relations executive, presents for management of perimenopausal symptoms. She reports hot flushes, night sweats, poor sleep, and mood fluctuations over the past 9 months. Her menstrual cycles are now irregular. She is not keen to use hormone replacement therapy (HRT) due to family history of breast cancer. Chloe has been trialling natural therapies including black cohosh, soy isoflavones, and evening primrose oil. She also practices yoga and mindfulness, which she finds helpful. She asks whether her current approach is safe and effective, and whether there are additional options available.

Medications: Black cohosh (40 mg/day), soy isoflavone capsules, evening primrose oil

Allergies: Nil known

Past history: Mild anxiety, no prior major illness

Family history: Mother diagnosed with ER-positive breast cancer at age 56

Social history: Non-smoker, drinks wine 1–2 times/week, pescatarian, regular yoga practice

Examination findings: Vitals normal, BMI 23. No abnormal findings on breast or pelvic exam

Investigations: FSH elevated at 32 IU/L, oestradiol low-normal, thyroid function normal, mammogram 6 months ago normal

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

Michael Chen, a 63-year-old retired teacher, presents seeking advice on natural approaches to support prostate health. He reports mild lower urinary tract symptoms (LUTS) including hesitancy, nocturia (twice per night), and a weak stream. His most recent PSA was 2.6 ng/mL (age-adjusted normal), and digital rectal examination revealed a mildly enlarged but smooth prostate. He is reluctant to start alpha-blockers due to fear of side effects and is currently taking saw palmetto and pumpkin seed oil capsules. He also practises pelvic floor exercises and avoids caffeine and alcohol. Michael asks whether his supplements are appropriate and if there are other non-pharmacological options available.

Medications: Saw palmetto extract 320 mg/day, pumpkin seed oil, PRN paracetamol for joint pain

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Family history: Father had benign prostatic hyperplasia (BPH)

Social history: Non-smoker, walks daily, pescatarian, no alcohol

Examination findings: BP 124/78, BMI 24. DRE: mildly enlarged, non-nodular prostate. No bladder distension

Investigations: PSA 2.6 ng/mL, eGFR 82, urinalysis normal. IPSS: 9 (mild symptoms)

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

Fatima Siddiqui, a 41-year-old social worker, presents with a longstanding history of migraines. She experiences 2–3 migraines per month, each lasting around 24 hours with moderate to severe pain, photophobia, and nausea. She uses sumatriptan and paracetamol during attacks, which provide partial relief. Fatima wishes to reduce her reliance on medications and asks about natural strategies. She is currently using magnesium glycinate (400 mg daily), riboflavin (vitamin B2), and coenzyme Q10, and has recently started acupuncture sessions. She also follows a mostly plant-based diet and tracks her migraines using an app. She asks whether her current plan is reasonable and what else could be considered.

Medications: Sumatriptan PRN, magnesium glycinate, riboflavin, CoQ10

Allergies: Nil known

Past history: Migraines since adolescence, mild anxiety

Family history: Mother and sister also experience migraines

Social history: Non-smoker, no alcohol, pescatarian, regular yoga practice

Examination findings: BP 118/72, BMI 22. Neurological exam normal, no red flag features

Investigations: No recent imaging. Last MRI (2 years ago) was normal

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

Emily Baxter, a 35-year-old high school teacher, presents seeking support for managing polycystic ovary syndrome (PCOS) using natural therapies. She has irregular menstrual cycles, mild hirsutism, and is trying to conceive. Ultrasound confirmed polycystic ovarian morphology, and blood tests showed mildly elevated androgens and fasting insulin. Emily is currently using inositol (myo-inositol and D-chiro-inositol), spearmint tea, and follows a low-GI, plant-focused diet. She is also taking a prenatal multivitamin and doing yoga three times a week. She is keen to avoid metformin unless necessary. Emily asks whether her current regimen is supported by evidence and what else she could consider to improve her fertility naturally.

Medications: Inositol (2 g BID), prenatal vitamin, spearmint tea

Allergies: Nil known

Past history: PCOS diagnosed 2 years ago, otherwise well

Family history: Mother has type 2 diabetes, sister has PCOS

Social history: Non-smoker, pescatarian, BMI 26, regular yoga

Examination findings: Normal BP, mild facial hirsutism, no acne or acanthosis nigricans

Investigations: Fasting insulin 18 (high), total testosterone elevated, LH:FSH ratio >2, pelvic ultrasound confirms polycystic ovaries

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

Jack Morrison, a 59-year-old carpenter, presents to discuss ongoing symptoms of mild depression and fatigue. He reports low mood, poor concentration, early morning wakening, and reduced motivation for the past 6 months. He denies suicidality. Jack has previously tried an SSRI but experienced sexual dysfunction and discontinued it after 3 weeks. He is currently self-managing with St John’s Wort, SAMe (S-adenosylmethionine), and regular morning walks. He also practises breathing exercises and has reduced alcohol intake. Jack asks whether his current regimen is effective and safe, and what other options he might consider without returning to antidepressants.

Medications: St John’s Wort (900 mg/day), SAMe 400 mg BID

Allergies: Nil known

Past history: Mild to moderate depression, no hospitalisations

Family history: Sister has depression, managed with medication and CBT

Social history: Lives alone, non-smoker, occasional alcohol, eats a Mediterranean-style diet

Examination findings: BMI 25, vitals normal. PHQ-9: 13, GAD-7: 6. No cognitive or neurological deficits

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

Olivia Tran, a 29-year-old office worker, presents for support with managing endometriosis-related pain using natural and integrative therapies. She has a confirmed diagnosis of stage 2 endometriosis following laparoscopy two years ago. Olivia experiences moderate pelvic pain around her periods and mild fatigue but does not want to restart the oral contraceptive pill due to past side effects. She currently uses turmeric (curcumin), omega-3 fish oil, and a TCM (Traditional Chinese Medicine) herbal formula prescribed by a registered Chinese medicine practitioner. She also follows an anti-inflammatory diet and practices yoga and meditation regularly. Olivia asks whether her approach is safe and effective and what additional non-hormonal options might help.

Medications: Turmeric (curcumin 500 mg BID), omega-3 fish oil (2000 mg/day), TCM herbal formula (contents unknown)

Allergies: Nil known

Past history: Laparoscopically confirmed endometriosis, history of dysmenorrhoea

Family history: Sister with endometriosis

Social history: Non-smoker, pescatarian, exercises regularly

Examination findings: BMI 22, mild lower abdominal tenderness, no masses or signs of acute inflammation

Investigations: Pelvic ultrasound: normal ovaries, no endometriomas

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

Nina Edwards, a 67-year-old retired school principal, presents for ongoing management of mild cognitive impairment (MCI). She has noticed some recent forgetfulness, such as misplacing items and occasional word-finding difficulty, but remains independent in daily activities. A neuropsychological assessment confirmed MCI. Nina is highly motivated to preserve her cognitive function and has started using ginkgo biloba, omega-3 supplements, and a daily mindfulness meditation practice. She follows a Mediterranean diet and exercises regularly. She asks if her current regimen is supported by evidence and whether other strategies could help.

Medications: Ginkgo biloba extract (120 mg/day), omega-3 fish oil (1000 mg/day), no prescription medications

Allergies: Nil known

Past history: Hypertension (diet-controlled), hyperlipidaemia

Family history: Mother had dementia in her 80s

Social history: Non-smoker, drinks red wine occasionally, pescatarian diet

Examination findings: MMSE 28/30, BP 126/78, BMI 23. No neurological deficits

Investigations: Vitamin B12: 230 pmol/L (normal), TSH normal, cholesterol slightly elevated. No neuroimaging abnormalities

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

Samuel Blake, a 52-year-old music teacher, presents seeking integrative support for chronic lower back pain. He has experienced intermittent pain for over five years, with no red flag symptoms. Imaging two years ago revealed mild lumbar spondylosis without disc herniation or spinal stenosis. Samuel reports daily discomfort, particularly after prolonged sitting, and occasional stiffness in the morning. He currently uses a combination of yoga, magnesium supplementation, turmeric capsules, and weekly osteopathy sessions. He avoids NSAIDs due to a history of gastritis and prefers to manage his pain without opioids. Samuel asks whether his current regimen is reasonable and if anything else may help.

Medications: Turmeric (curcumin 500 mg BID), magnesium citrate 300 mg/day

Allergies: Nil known

Past history: Chronic non-specific low back pain, gastritis

Family history: Non-contributory

Social history: Non-smoker, occasional red wine, pescatarian diet, walks daily

Examination findings: BMI 24, mild paraspinal tenderness in the lumbar region, normal reflexes and strength, negative straight leg raise

Investigations: Lumbar spine X-ray (2 years ago): mild degenerative changes. No red flags present

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

Amara Singh, a 45-year-old community health worker, presents seeking integrative strategies for managing persistent perimenopausal insomnia. She reports difficulty falling asleep and frequent nocturnal waking over the past 8 months. These symptoms are affecting her concentration and mood. Amara experiences occasional hot flushes but does not want to take hormone therapy due to a strong family history of breast cancer. She currently uses valerian root, low-dose melatonin (2 mg SR), and magnesium glycinate. She also practises yoga, limits screen use before bed, and follows a caffeine-free, whole-food diet. She asks whether her current approach is effective and if there are additional options to consider.

Medications: Melatonin 2 mg SR, valerian root 500 mg at night, magnesium glycinate 300 mg/day

Allergies: Nil known

Past history: Perimenopausal symptoms, mild anxiety

Family history: Mother diagnosed with ER-positive breast cancer at age 50

Social history: Non-smoker, pescatarian, non-drinker, regular mindfulness practice

Examination findings: Vitals normal, BMI 23, no thyroid enlargement or tremor. Menstrual cycles irregular

Investigations: FSH elevated (30 IU/L), oestradiol low-normal, TSH normal, ferritin normal

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

James O’Connor, a 60-year-old environmental scientist, presents for advice on managing mild hypertension using lifestyle and natural therapies. His most recent blood pressure readings are around 138/86 mmHg. He is not on any antihypertensive medications and prefers to avoid them for now. James follows a predominantly plant-based Mediterranean diet, practices daily meditation, and walks 45 minutes each day. He recently started using garlic extract, hibiscus tea, and coenzyme Q10. He asks whether these strategies are effective and what else he can do to prevent needing medication.

Medications: Garlic extract 600 mg/day, CoQ10 100 mg/day, hibiscus tea twice daily

Allergies: Nil known

Past history: Mild hypertension, mild dyslipidaemia

Family history: Father had stroke at age 67, mother has hypertension

Social history: Non-smoker, pescatarian, drinks wine occasionally, no caffeine

Examination findings: BP average 138/86 mmHg, BMI 23, waist circumference 88 cm. Cardiovascular exam normal

Investigations: Lipids: Total cholesterol 5.2, HDL 1.3, LDL 3.1, triglycerides 1.5. HbA1c 5.4%, eGFR 90

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

Rachel Delaney, a 38-year-old lawyer, presents with ongoing symptoms of irritable bowel syndrome with constipation (IBS-C). She experiences bloating, abdominal discomfort, and infrequent bowel movements (every 3–4 days), often associated with incomplete evacuation. She has tried laxatives and fibre supplements with limited success. Rachel is now using peppermint oil, triphala (an Ayurvedic herbal formula), and psyllium husk. She follows a low-FODMAP diet and practises mindfulness and diaphragmatic breathing exercises. She asks whether her current approach is appropriate and what else might help manage her symptoms.

Medications: Enteric-coated peppermint oil, triphala capsules, psyllium husk (1 tsp BID)

Allergies: Nil known

Past history: IBS-C diagnosed 2 years ago, iron deficiency in the past (now resolved)

Family history: Mother has hypothyroidism

Social history: Non-smoker, pescatarian, moderate coffee intake, no alcohol

Examination findings: BMI 22, abdomen soft, mildly distended, no masses or tenderness

Investigations: TSH normal, coeliac serology negative, recent colonoscopy normal

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

Thomas Wilcox, a 70-year-old retired pharmacist, presents seeking support for managing osteopenia with lifestyle and natural therapies. He was diagnosed with osteopenia based on a recent DEXA scan showing a T-score of -1.8 at the femoral neck. He has no history of fractures. Thomas prefers to avoid bisphosphonates at this stage and is currently using vitamin D3, calcium citrate, and vitamin K2. He also performs weight-bearing exercise, tai chi, and follows a Mediterranean diet. He asks whether his current regimen is sufficient and whether there are other natural options to consider for bone health.

Medications: Vitamin D3 (1000 IU/day), calcium citrate (500 mg BID), vitamin K2 (MK-7 90 mcg/day)

Allergies: Nil known

Past history: Hypertension, well controlled

Family history: Mother had hip fracture at age 82

Social history: Non-smoker, pescatarian, no alcohol, walks daily

Examination findings: BMI 23, BP 122/78, no spinal tenderness or deformity, normal gait and posture

Investigations: DEXA scan: T-score -1.8 (femoral neck), Vitamin D 74 nmol/L, eGFR 80, calcium and phosphate normal

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

Leila Haddad, a 50-year-old yoga instructor, presents for integrative support in managing chronic fatigue symptoms. Over the past year, she has experienced persistent low energy, post-exertional malaise, unrefreshing sleep, and brain fog. She was previously assessed by a physician and diagnosed with chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), after exclusion of other causes. Leila currently uses magnesium, B-complex vitamins, and Rhodiola rosea (an adaptogenic herb). She also paces her activities and uses restorative yoga and mindfulness. She asks whether her regimen is safe and supported by evidence and what else might assist in managing her symptoms.

Medications: Magnesium glycinate 300 mg/day, B-complex (includes B12 500 mcg), Rhodiola rosea 200 mg/day

Allergies: Nil known

Past history: Chronic fatigue syndrome diagnosed 18 months ago

Family history: Mother has fibromyalgia

Social history: Non-smoker, pescatarian, minimal alcohol, practices daily mindfulness

Examination findings: BMI 21, normal vitals, no focal neurological signs

Investigations: Normal FBC, TSH, B12, iron studies, CRP, and liver/renal function. No sleep apnoea or autoimmune disease identified

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

Ella Johansson, a 32-year-old landscape designer, presents seeking integrative support for managing anxiety. She reports persistent symptoms of restlessness, difficulty concentrating, muscle tension, and occasional palpitations. These symptoms have been present for over a year but have worsened in recent months due to work stress. Ella is reluctant to use prescription anxiolytics and is currently taking ashwagandha, L-theanine, and magnesium glycinate. She also practises meditation, exercises regularly, and has reduced her caffeine intake. She asks whether her current approach is appropriate and whether there are additional non-pharmacological strategies she should consider.

Medications: Ashwagandha extract 600 mg/day, L-theanine 200 mg BID, magnesium glycinate 300 mg/day

Allergies: Nil known

Past history: Mild anxiety, no previous mental health medication

Family history: Mother has generalised anxiety disorder, father has hypertension

Social history: Non-smoker, pescatarian, occasional alcohol, lives with partner

Examination findings: Vitals normal, BMI 22. No signs of thyrotoxicosis. DASS-21: mild to moderate anxiety

Investigations: TSH and iron studies normal, ECG unremarkable. No red flags for organic pathology

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

Daniel Fraser, a 58-year-old school principal, presents for advice on supporting metabolic health through natural therapies. He has recently been diagnosed with metabolic syndrome, with elevated waist circumference, mildly raised fasting glucose, hypertension, and dyslipidaemia. Daniel is highly motivated to avoid medications for now and is trialling lifestyle changes along with berberine, cinnamon extract, and omega-3 supplements. He follows a Mediterranean diet, practises intermittent fasting, and walks daily. He asks whether his current approach is evidence-informed and what else might support improvement in his metabolic profile.

Medications: Berberine 500 mg BID, cinnamon extract 1 g/day, omega-3 fish oil 1000 mg/day

Allergies: Nil known

Past history: Borderline hypertension, family history of T2DM

Family history: Father had T2DM and coronary artery disease

Social history: Non-smoker, pescatarian, no alcohol

Examination findings: BMI 27, waist circumference 104 cm, BP 138/84 mmHg

Investigations: Fasting glucose 6.2 mmol/L, HbA1c 5.9%, total cholesterol 5.4 mmol/L, HDL 0.9, LDL 3.3, triglycerides 2.1 mmol/L, eGFR 88

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

Kai Nguyen, a 27-year-old postgraduate student, presents seeking support for recurrent tension-type headaches and fatigue. He experiences mild to moderate headaches on 3–4 days per week, described as a tight band-like pressure around the temples and occiput. They are not associated with nausea or visual changes. Kai also reports low energy, poor sleep quality, and difficulty concentrating. He has been using magnesium glycinate, riboflavin, and a blend of adaptogenic herbs including Rhodiola and holy basil. He also practises regular yoga, uses a standing desk, and avoids excessive screen time. He asks whether his current regimen is appropriate and what else might help improve both headache and energy levels.

Medications: Magnesium glycinate 400 mg/day, riboflavin 200 mg/day, adaptogenic herbal blend (Rhodiola, holy basil)

Allergies: Nil known

Past history: No chronic illness. Frequent tension-type headaches for past 12 months

Family history: Sister has migraine, mother has hypothyroidism

Social history: Non-smoker, pescatarian, occasional alcohol, long study hours

Examination findings: BP 116/74, BMI 22. Cervical and shoulder muscle tenderness. Neuro exam normal

Investigations: FBC, iron studies, B12, TSH all within normal limits

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

Layla Karim, a 44-year-old graphic designer, presents with concerns about recurrent eczema flare-ups and is interested in integrative strategies to manage her skin health. She has a long-standing history of atopic dermatitis, with dry, itchy patches affecting her forearms, hands, and neck. Layla uses topical corticosteroids sparingly due to concern about long-term skin thinning and prefers a more natural approach. She currently takes evening primrose oil, probiotics, and vitamin D. She also follows a plant-rich anti-inflammatory diet, uses fragrance-free skin care products, and practises stress-reducing techniques such as breathwork. Layla asks whether her current regimen is safe and effective and if anything else can help reduce flare frequency.

Medications: Evening primrose oil 1000 mg BID, vitamin D 1000 IU/day, probiotic supplement containing Lactobacillus rhamnosus GG

Allergies: Nil known

Past history: Atopic dermatitis since childhood, mild allergic rhinitis

Family history: Mother has asthma, sister has eczema

Social history: Non-smoker, pescatarian, works mostly from home

Examination findings: Dry, erythematous patches with excoriations on flexural forearms and wrists. No signs of secondary infection

Investigations: Vitamin D 58 nmol/L, eosinophils mildly elevated, IgE elevated

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

Zara Rahman, a 36-year-old secondary school teacher, presents seeking integrative support for recurrent urinary tract infections (UTIs). She has experienced four culture-confirmed UTIs in the past year, all responsive to short courses of antibiotics. Zara is concerned about antibiotic overuse and is interested in preventing recurrences naturally. She is currently using D-mannose powder, cranberry extract, and a probiotic containing Lactobacillus rhamnosus GR-1 and L. reuteri RC-14. She also increases her fluid intake and practises good perineal hygiene. Zara asks if these strategies are supported by evidence and whether any other preventative options should be considered.

Medications: D-mannose 2 g daily, cranberry extract 500 mg/day, probiotic (L. rhamnosus GR-1 and L. reuteri RC-14)

Allergies: Nil known

Past history: Recurrent uncomplicated UTIs, otherwise healthy

Family history: Non-contributory

Social history: Non-smoker, sexually active in monogamous relationship, pescatarian diet

Examination findings: Vitals normal, abdomen soft, no suprapubic or costovertebral angle tenderness

Investigations: Urinalysis normal today. Recent MSU: E. coli sensitive to trimethoprim. Renal function normal. No structural abnormalities

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

Harriet Moore, a 65-year-old retired librarian, presents seeking integrative strategies to support her osteoarthritis (OA) of the knees. She experiences daily discomfort, especially when walking or using stairs, but prefers to avoid NSAIDs due to a history of gastritis. She currently uses turmeric capsules, glucosamine sulfate, and omega-3 fish oil. She also participates in aqua aerobics twice weekly and follows a Mediterranean-style diet. Harriet asks whether her current supplements are appropriate and what else might help manage her symptoms without relying on pharmacological pain relief.

Medications: Turmeric (curcumin 500 mg BID), glucosamine sulfate 1500 mg/day, omega-3 fish oil 1000 mg/day

Allergies: Nil known

Past history: Knee osteoarthritis, gastritis, hypercholesterolaemia

Family history: Mother had OA, father had hypertension

Social history: Non-smoker, pescatarian, no alcohol, lives alone

Examination findings: BMI 26, bony enlargement of both knees, crepitus, mild effusion, no erythema or warmth

Investigations: Knee X-ray shows moderate joint space narrowing and osteophyte formation. Normal CRP, renal and liver function

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

Joel Patterson, a 48-year-old high school teacher, presents seeking integrative support for managing gastroesophageal reflux disease (GORD). He has experienced intermittent heartburn and regurgitation for several years, mostly after meals or when lying down. He has been using over-the-counter proton pump inhibitors (PPIs) intermittently but prefers not to take them long-term due to concerns about side effects. Joel has recently started taking deglycyrrhizinated licorice (DGL), slippery elm, and digestive enzymes. He also elevates the head of his bed and avoids late meals. He asks if his current approach is safe and whether other non-pharmacological strategies might be useful.

Medications: DGL chewable tablets before meals, slippery elm powder at night, broad-spectrum digestive enzymes with meals

Allergies: Nil known

Past history: GORD, no known Barrett’s oesophagus or peptic ulcer

Family history: Father has GORD, mother has type 2 diabetes

Social history: Non-smoker, pescatarian, drinks red wine socially, BMI 25.5

Examination findings: Vitals normal, no abdominal tenderness, BMI 25.5

Investigations: Recent gastroscopy (6 months ago): mild oesophagitis, no Barrett’s or malignancy. H. pylori negative

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