KFP – Justice system health

Dean Carter, aged 27, presents to your custodial clinic at a regional correctional facility. He is a new arrival, transferred from another facility two days ago. He requests a ‘mental health review’, stating he feels ‘on edge all the time’ and is having trouble sleeping. He denies thoughts of self-harm, but you note some healed scars on his forearms. He reports flashbacks related to past assaults in custody and difficulties trusting the prison staff. He has been in custody for 4 years on multiple assault charges, with another 18 months before parole eligibility. He has no visitors or outside support. You review his health records which document a prior diagnosis of PTSD and prior prescriptions for mirtazapine and quetiapine. His medication chart shows no current prescriptions. He states he was taken off medications due to a ‘disciplinary review’ two months ago. He reports no illicit drug use while in custody.

Medications: None currently prescribed

Allergies: Nil known

Past history: PTSD (diagnosed 3 years ago), previous head injury (assault-related)

Family history: Non-contributory

Social history: Grew up in state care, history of childhood trauma, no fixed address prior to incarceration

Psychiatric history: Multiple prior episodes of depression, chronic PTSD, past suicide attempt aged 19

Examination findings: Alert and oriented. Slight psychomotor agitation. Flat affect. Cooperates with examination. No delusions or hallucinations elicited.

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

Angela Toomey, aged 44, presents to the prison medical clinic requesting help with heavy vaginal bleeding. She has been in custody for six months and reports a history of irregular periods, now worsening in the past three months. She says her bleeding lasts 8–10 days, with flooding and clots. She feels tired all the time, dizzy when standing, and has had several recent episodes of light-headedness. She denies pregnancy and is sexually inactive since incarceration. She was previously on the depot medroxyprogesterone injection but hasn’t had it since entering prison. She has not seen a gynaecologist before and has never had a pap smear.

Medications: None

Allergies: Nil known

Past history: Smoking (15 pack-years), iron deficiency anaemia (untreated)

Family history: Mother had hysterectomy at age 45 for ‘heavy bleeding’

Social history: Incarcerated for non-violent drug offences, history of sexual abuse, no current partner, no children

Preventative Healthcare: No cervical screening recorded

Examination findings: Pale conjunctivae, HR 96 bpm, BP 98/56 mmHg, soft non-tender abdomen. Bimanual and speculum examination declined.

Investigations:
Full blood count:
Hb 86 g/L (120–160)
MCV 68 fL (80–96)
Ferritin 7 µg/L (20–200)

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

Raymond Holloway, aged 62, presents to the prison health clinic with fatigue, weight loss, and poor appetite over the past 6 weeks. He has a known history of hepatitis C (diagnosed 8 years ago) but has not been treated. He reports occasional right upper quadrant pain, pale stools, and dark urine. He denies alcohol use since incarceration 18 months ago. He has lost approximately 6 kg and reports increasing lethargy. He says he previously ‘got bloods done’ but never followed up. He is worried that he might be ‘getting liver cancer like his brother’.

Medications: Nil

Allergies: Nil known

Past history: Hepatitis C (genotype unknown), intravenous drug use (ceased 10 years ago), type 2 diabetes mellitus (diet-controlled), depression

Family history: Brother died of hepatocellular carcinoma at age 58

Social history: Long custodial sentence (violent offences), no contact with family, former heavy alcohol use

Examination findings: BMI 20.2 kg/m², scleral icterus, palmar erythema, spider naevi, hepatomegaly, no ascites, normal cognition and speech

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

Jasmine Farrell, aged 33, presents to the prison medical unit requesting a methadone restart. She says she was previously on a methadone program in the community but missed several doses after being arrested and remanded into custody three days ago. She describes symptoms of opioid withdrawal including abdominal cramps, muscle aches, insomnia, yawning, and anxiety. She denies suicidal ideation but appears visibly distressed and agitated during the consultation. She states she has been using intravenous heroin daily for the past two years and last used three days ago, just prior to her arrest. She reports no other drug use. She is unsure of her last methadone dose but estimates it was ‘about 70 mg a day’. She has never been in custody before and does not have her prescription details on her.

Medications: None currently

Allergies: Nil known

Past history: Opioid use disorder, hepatitis C (treated, SVR achieved), depression

Family history: Non-contributory

Social history: Unemployed, lives alone, high-risk drug use, no children

Examination findings: Diaphoretic, dilated pupils, BP 134/88 mmHg, HR 98 bpm, RR 18, temp 36.9°C. Clinical Opioid Withdrawal Scale (COWS) score = 16 (moderate withdrawal)

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

Frank Delaney, aged 48, presents to the prison medical clinic with a three-week history of chronic cough, weight loss, night sweats, and fatigue. He has been in custody for four months, sharing a cell with two others. He is a long-term smoker (20 cigarettes/day) and previously homeless. He was born in Vietnam and migrated to Australia in his 20s. He has not seen a doctor in years and has never had a chest x-ray. He denies haemoptysis. On examination he appears thin, mildly febrile (37.8°C), with a persistent dry cough during the consultation. No clubbing is observed. Chest auscultation reveals scattered crackles in the right upper lobe.

Medications: None

Allergies: Nil known

Past history: Smoker, unknown BCG status, alcohol dependence (now abstinent)

Social history: Former rough sleeper, recent entry into custodial system, no family contacts

Examination findings: T 37.8°C, HR 90 bpm, BP 124/80 mmHg, RR 20, SpO₂ 98% RA, BMI 18.9 kg/m²

Investigations: FBC: mild normocytic anaemia; ESR 84 mm/hr (elevated)

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

Levi Morrison, aged 19, is brought to the prison health unit by correctional officers after engaging in self-harm. He cut his left forearm with a razor blade found in his cell. He appears withdrawn and minimally responsive. Officers report that he has been isolating, not attending education sessions, and has been involved in two recent altercations. He was recently sentenced to an 18-month custodial term for aggravated burglary and has no previous prison experience. He has a documented history of childhood trauma, depression, and suicide attempt at age 14. This is his third week in custody.

Medications: None

Allergies: Nil known

Past history: Major depressive disorder, past self-harm, ADHD (diagnosed in childhood)

Family history: Mother with bipolar disorder, father incarcerated during his childhood

Social history: Ward of the state until age 18, no family contact, unstable housing, no substance dependence

Examination findings: Laceration on forearm, approximately 4 cm, superficial, clean. No active bleeding. Appears flat, avoids eye contact, responds to direct questions in monosyllables. Denies current suicidal intent but states he feels ‘nothing’s worth it’.

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

Philip Roach, aged 58, presents to the prison medical clinic with complaints of numbness and tingling in both feet, unsteadiness when walking, and occasional burning pain in the soles of his feet, worsening over the past six months. He is currently serving a seven-year sentence and has been in custody for 18 months. He has a history of type 2 diabetes mellitus and alcohol use disorder. He drinks no alcohol in custody but reports drinking a bottle of spirits most days prior to incarceration. He denies recent head injury, visual disturbance, or bowel/bladder issues.

Medications: Metformin 1 g BD

Allergies: Nil known

Past history: Type 2 diabetes mellitus (diagnosed 10 years ago), hypertension, chronic alcohol use (ceased on incarceration)

Family history: Father had type 2 diabetes and stroke

Social history: Former construction worker, lived alone, socially isolated prior to incarceration

Examination findings: Vibration sensation reduced to knees bilaterally, absent ankle reflexes, stocking-distribution sensory loss to mid-calf, unsteady gait on tandem walking, no cranial nerve deficits

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

Donna Strickland, aged 41, presents to the prison medical unit with complaints of difficulty sleeping and frequent nightmares. She says she has been in prison for 4 months and the nightmares have become worse since being placed in solitary confinement for disciplinary reasons two weeks ago. She describes being ‘on edge all the time’, experiencing intrusive memories of her childhood and domestic violence, and sometimes feels ‘like it’s all happening again’. She avoids talking to staff and other inmates, preferring to stay in her cell. She admits to previous self-harm, but denies current suicidal ideation. She was previously prescribed medication in the community but is unsure what it was.

Medications: None currently

Allergies: Nil known

Past history: Complex PTSD, sexual and domestic abuse, previous benzodiazepine misuse

Family history: Non-contributory

Social history: Unemployed, no fixed address before custody, estranged from family

Examination findings: Alert, tense, poor eye contact, hypervigilant. No psychosis. Cooperates minimally with the examination. Normal physical examination.

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

Stephen Bennett, aged 36, presents to the prison medical unit complaining of persistent lower back pain for the past four months. He describes the pain as dull and aching, worse in the mornings, and improving slightly with movement. He has a history of intravenous drug use and is serving a 10-year sentence. He denies recent trauma, but reports general fatigue, night sweats, and a 5 kg weight loss over the past three months. He has not responded to paracetamol or ibuprofen. He denies bladder or bowel incontinence but occasionally reports numbness in his left leg. He has no history of back surgery.

Medications: None

Allergies: Nil known

Past history: Hepatitis C (treated), intravenous drug use (ceased), cellulitis, depression

Social history: Lived on streets intermittently before incarceration, no regular GP

Examination findings: Tenderness over L4-L5 spinous processes, decreased range of lumbar motion, no motor deficits. Reduced pinprick sensation in L5 dermatomal distribution. Reflexes normal. Straight leg raise negative bilaterally.

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

Ahmed Youssef, aged 31, presents to the prison health clinic requesting help for ongoing dental pain. He reports a throbbing pain in the lower left jaw for the past 5 days, worsened by chewing. He also has mild facial swelling and difficulty sleeping. He denies trauma but says he has had multiple broken teeth for years and has been ‘pulling bits out’ himself. He has been in custody for 2 months and has not accessed dental care. He admits to smoking and methamphetamine use prior to incarceration. He appears anxious and requests ‘stronger painkillers’.

Medications: Nil

Allergies: Nil known

Past history: Methamphetamine use disorder, dental neglect, anxiety

Social history: Unemployed, unstable housing prior to incarceration, poor oral hygiene

Examination findings: Swelling over the left mandibular angle, tenderness over molars, halitosis, visible caries in multiple teeth. No trismus. No fever. Mild submandibular lymphadenopathy. Normal vital signs.

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

Victor Green, aged 72, is brought to the prison medical unit by custodial staff after multiple reports of confusion and verbal aggression towards other inmates. He has been in custody for 3 weeks on remand and has no previous prison history. Staff report that he has been disoriented, asking for deceased family members, and wandering at night. He is usually quiet and compliant. His cellmate reports that he ‘talks to himself’ and urinates in the corner at night. Victor has a long-standing history of hypertension and reports vague memory problems for the past few years.

Medications: Perindopril 4 mg daily

Allergies: Nil known

Past history: Hypertension, possible dementia (undiagnosed), no known psychiatric illness

Family history: Brother had Alzheimer’s disease

Social history: Lived alone prior to incarceration, no children, estranged from family

Examination findings: Dishevelled, intermittently agitated, oriented to person only. MMSE: 19/30. BP 144/78 mmHg, HR 82, afebrile. No focal neurological deficits. Urinalysis shows positive leukocytes and nitrites.

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

Travis Johnston, aged 24, presents to the prison health unit complaining of frequent episodes of shortness of breath and chest tightness, particularly during exercise and at night. He reports a persistent dry cough and uses a friend’s salbutamol inhaler ‘most days’. He has been in custody for 5 months and says he had ‘bad asthma’ as a child but stopped treatment in his teens. He smokes hand-rolled tobacco daily and often shares cigarettes. He sleeps in a cell with two other smokers. He has not been hospitalised for asthma recently but recalls going to ED several times in childhood.

Medications: None

Allergies: Nil known

Past history: Childhood asthma, hay fever

Social history: Daily smoker, low literacy, unemployed prior to incarceration

Examination findings: Expiratory wheeze on auscultation, mild tachypnoea, SpO₂ 97% on room air. No signs of acute respiratory distress. PEFR: 330 L/min (predicted 500)

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

Marita Kelleher, aged 38, is brought to your prison medical clinic by correctional staff after refusing meals for the past 4 days. She states that she is on a ‘hunger strike’ due to unfair treatment by officers but admits she has also been hearing voices telling her she’s being watched. She appears paranoid and distressed. She was transferred from another correctional facility 3 weeks ago and has no prior prison health records on file. She says she has been treated for mental illness in the past but refuses to say more. Staff report increasing agitation and isolation in the past week. She has no known physical comorbidities.

Medications: None currently prescribed

Allergies: Nil known

Past history: Unknown psychiatric history

Social history: No contact with family, frequent prior incarcerations

Examination findings: Thin, appears internally preoccupied, avoids eye contact, answers questions reluctantly. No acute distress, but speech is occasionally tangential. Vitals within normal range. BMI estimated at 17.5 kg/m².

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

Charlie Ngatai, aged 46, presents to the prison health unit with complaints of persistent itching and skin sores. He has been in custody for 3 weeks and says the rash started about a week ago and has been spreading. He describes it as intensely itchy, especially at night. On examination, he has excoriated papules and burrows between the fingers, wrists, and along the waistband. Several cellmates have reported similar symptoms. Charlie is visibly distressed and says he hasn’t been sleeping well due to the itching.

Medications: Nil

Allergies: Nil known

Past history: Asthma, eczema (childhood only)

Social history: Sharing a dormitory-style cell with five other men, some of whom have skin complaints

Examination findings: Multiple excoriations, burrows in webspaces and wrists, erythematous papules over trunk and groin. No signs of secondary bacterial infection. Afebrile, stable vitals.

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

Reece Donovan, aged 29, presents to the prison clinic for a routine hepatitis C follow-up. He completed a 12-week course of direct-acting antivirals (glecaprevir/pibrentasvir) six months ago while in custody. He reports feeling well, has gained weight, and has no ongoing symptoms. He has been abstinent from injecting drug use since incarceration and attends the prison harm minimisation education sessions. You review his file and note that an HCV RNA test was ordered 12 weeks after treatment but the result is not documented.

Medications: None

Allergies: Nil known

Past history: Chronic hepatitis C (genotype 3), IV drug use (ceased 10 months ago), no cirrhosis

Social history: Tattooed, former IV drug use, serving 3-year sentence, no history of alcohol use disorder

Examination findings: Well appearing, BMI 23 kg/m², no stigmata of chronic liver disease, normal vitals

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

Jessica Harding, aged 35, presents to the prison medical clinic reporting vaginal discharge and lower abdominal discomfort for the past 5 days. She describes the discharge as yellow with an unpleasant odour. She denies fever or vomiting but reports mild suprapubic tenderness. She has been sexually active with one male inmate via sanctioned conjugal visits. Her last menstrual period was two weeks ago and was normal. She has not had a cervical screening test in over 10 years and was not accessing regular healthcare prior to incarceration. She does not use condoms consistently and is worried about STIs.

Medications: Nil

Allergies: Nil known

Past history: Irregular access to healthcare, possible prior chlamydia infection (untreated)

Social history: Smoking, prior IV drug use, serving a 5-year custodial sentence

Examination findings: Afebrile, mild suprapubic tenderness, no rebound or guarding. Speculum exam shows mucopurulent discharge and cervical motion tenderness.

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

Darren McNally, aged 52, is referred to the prison medical clinic after multiple complaints from unit staff about his hygiene and unusual behaviours. He has been seen speaking to himself, smearing faeces in his cell, and refusing to shower. He was transferred from another correctional facility 2 weeks ago. His records note a prior diagnosis of schizophrenia and prior treatment with depot antipsychotics, but he is currently not on any medication. He is serving a long sentence for non-violent offences. Staff report that he is not aggressive but is increasingly withdrawn and socially isolated.

Medications: None

Allergies: Nil known

Past history: Schizophrenia (poor adherence), past homelessness, tobacco dependence

Social history: No family contact, has been in and out of custody for most of adult life

Examination findings: Dishevelled appearance, poor eye contact, mumbling to self, flat affect, oriented to person but not time or place. Responds to internal stimuli. Physically well, afebrile, normal observations.

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

Layla Thompson, aged 22, presents to the prison clinic with persistent fatigue, difficulty concentrating, and feeling ‘low and hopeless’. She was remanded to custody three weeks ago on drug-related charges and is visibly distressed about being separated from her two-year-old daughter, who is now in temporary care. She has no significant medical history but reports poor sleep, weight loss, and a history of self-harm as a teenager. She is tearful during the consult and says she ‘doesn’t see the point anymore’. She denies current suicidal ideation but describes feeling numb and passive.

Medications: None

Allergies: Nil known

Past history: Childhood trauma, adolescent self-harm, suspected depression (never treated)

Social history: Sole parent, on remand, no family supports, history of unstable housing

Examination findings: Flat affect, slowed speech, no hallucinations or delusions elicited. Oriented and cooperative. Vitals within normal range.

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

Rangi Te Huia, aged 39, is brought to the prison medical unit following an incident in which he was found unconscious in his cell. He regained consciousness within minutes and now appears alert but confused. He has a known history of alcohol use disorder, and staff report he had been sweating, shaking, and agitated over the last two days. He has been in custody for four days on remand and had no access to alcohol since entering. He admits to drinking a bottle of vodka daily prior to incarceration. He has no documented withdrawal management plan.

Medications: None

Allergies: Nil known

Past history: Alcohol use disorder, one prior hospitalisation for withdrawal seizures

Social history: Māori, unemployed, history of rough sleeping, socially isolated

Examination findings: HR 112 bpm, BP 154/98 mmHg, RR 20, Temp 37.9°C. Confused, tremulous, diaphoretic. No focal neurological signs.

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

Benjamin Foster, aged 62, presents to the prison medical clinic complaining of increasing breathlessness, fatigue, and a chronic cough productive of clear sputum. He was recently transferred from another facility and has a long smoking history (40 pack-years). He denies chest pain or recent infections. He has never seen a respiratory specialist and was last reviewed by a GP over five years ago. He continues to smoke daily in prison and says he’s ‘not interested in quitting’.

Medications: Nil

Allergies: Nil known

Past history: COPD (undiagnosed but suspected), hypertension

Social history: Long-term incarceration, former labourer, continued tobacco use, limited health engagement

Examination findings: SpO₂ 94% on room air, bilateral wheeze and reduced breath sounds, RR 18, BP 138/86, HR 84 bpm, afebrile

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

Ali Rahman, aged 27, presents to the prison medical clinic for follow-up after a positive Mantoux test performed during his routine intake screening. He is asymptomatic, denies cough or weight loss, and is afebrile. He reports arriving in Australia from Afghanistan as a child and has never been treated for tuberculosis. He was previously in a detention facility but has not travelled internationally recently. There is no known contact with active TB cases within the prison. Chest x-ray performed yesterday shows no evidence of active pulmonary disease.

Medications: Nil

Allergies: Nil known

Past history: BCG vaccinated as infant, no known prior TB or treatment

Social history: Non-smoker, serving a 2-year sentence, living in shared cell

Examination findings: Well, BMI 22, chest clear, no lymphadenopathy, SpO₂ 98% on room air

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

Eliza Morgan, aged 45, presents to the prison medical clinic with ongoing difficulty managing her type 1 diabetes since arriving in custody 3 weeks ago. She reports fluctuating blood sugar levels, occasional nausea, and a fear of experiencing hypoglycaemia in her cell overnight. She previously used an insulin pump in the community but now receives twice-daily mixed insulin administered by nursing staff. She expresses frustration at the loss of control over her condition and has become withdrawn and tearful. There is no evidence of acute illness.

Medications: Biphasic insulin 30/70 BD via nursing supervision

Allergies: Nil known

Past history: Type 1 diabetes mellitus (since age 16), anxiety disorder, coeliac disease

Social history: Remanded in custody, previously living independently, highly engaged in her own care

Examination findings: BMI 22 kg/m², no signs of infection or ketoacidosis, capillary BGLs fluctuate between 3.4–18 mmol/L, mild orthostatic hypotension, appears anxious

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

Joshua Pike, aged 33, presents to the prison medical clinic after developing painful, raised skin lesions on his arms and trunk over the past 5 days. He reports associated joint stiffness and fatigue. He has a history of injecting drug use and was recently treated for a skin abscess. He denies fever or recent antibiotic use. Examination reveals multiple tender, erythematous nodules on both forearms and shins. There is no evidence of pus or ulceration. He appears well but concerned.

Medications: Nil

Allergies: Nil known

Past history: Hepatitis C (treated), injecting drug use, history of skin infections

Social history: Serving a 4-year sentence, shares a cell, continues to smoke, no current injecting use

Examination findings: Afebrile, multiple erythematous nodules consistent with erythema nodosum, mild ankle swelling, normal vital signs

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

Karen Douglas, aged 57, presents to the prison health clinic with frequent urination, nocturia, and increasing thirst over the past few months. She has also noticed unintentional weight loss and general fatigue. She has been in custody for 2 months. Her BMI is 29 kg/m². She denies urinary pain, fever, or incontinence. She reports a family history of diabetes but has never been diagnosed herself. Her blood pressure is 138/82 mmHg and capillary blood glucose reading at presentation is 17.4 mmol/L.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (previously untreated), osteoarthritis

Family history: Type 2 diabetes mellitus (mother, brother)

Social history: Lives alone in the community, recently incarcerated, no known substance use

Examination findings: Mild acanthosis nigricans at neck, no signs of infection or dehydration. Urine dipstick: glucose ++, ketones –

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

Maxwell Lane, aged 48, presents to the prison health unit with worsening knee pain, particularly when walking up stairs or standing for long periods. He reports a history of a knee injury from his time working in construction and says the pain has gradually worsened since entering custody six months ago. He has difficulty participating in yard-based exercise and feels increasingly frustrated by reduced mobility. He requests stronger pain relief, saying ‘the Panadol does nothing’.

Medications: Paracetamol 1 g TDS

Allergies: Nil known

Past history: Chronic knee pain, hypertension, smoker

Social history: Former labourer, serving a 7-year sentence, lives in shared accommodation, no drug use history

Examination findings: Right knee: mild effusion, reduced flexion, crepitus on movement, medial joint line tenderness. No warmth or erythema. No ligamentous instability. BMI 30 kg/m²

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

Samuel Tai, aged 31, is brought to the prison clinic by officers after being found pacing and praying loudly in his cell, stating he is ‘chosen to cleanse the wicked’. He has not slept for several nights and has been refusing food, claiming it is poisoned. He has a known diagnosis of schizoaffective disorder and had been stable on long-acting injectable antipsychotics prior to transfer from another prison three weeks ago. His medical file reveals he missed his last depot dose due to a transfer delay. He is not currently on any psychiatric medication.

Medications: None currently

Allergies: Nil known

Past history: Schizoaffective disorder, previous admissions for psychosis, long-acting injectable risperidone

Social history: No family contact, history of incarceration and housing instability

Examination findings: Agitated, pressured speech, grandiose and paranoid delusions, guarded, no physical abnormalities, vitals normal

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

Anthony Costa, aged 60, presents to the prison medical clinic with a complaint of chronic constipation. He reports opening his bowels only once every 5–6 days with hard, dry stools and occasional abdominal discomfort. He has been incarcerated for 3 months and attributes the problem to the prison diet and lack of exercise. He denies nausea, vomiting, blood in the stool, or weight loss. He takes codeine/paracetamol occasionally for back pain. He drinks minimal water and avoids using the communal toilets.

Medications: Paracetamol/codeine PRN

Allergies: Nil known

Past history: Chronic low back pain, diverticulosis, hypertension

Social history: Sedentary, low fluid intake, no prior colonoscopy, long-term smoker, custodial sentence 2 years

Examination findings: Soft abdomen, non-tender, no masses, bowel sounds present. PR: hard stool in rectum, no blood or masses

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

Tamara Wells, aged 26, presents to the prison medical clinic requesting emergency contraception. She discloses that during a recent conjugal visit with her long-term partner, the condom broke. She is unsure of her exact menstrual dates but believes the incident occurred ‘a couple of days after my period ended’. She is not currently using any regular contraception and has no known medical conditions. This is her first time seeking healthcare in custody.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Remanded in custody, non-smoker, no substance use history, in a stable relationship

Examination findings: Well, normal vital signs, no abdominal or pelvic tenderness, not visibly distressed

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

Steven Long, aged 50, presents to the prison clinic with persistent hoarseness and a sore throat that has lasted over six weeks. He denies fevers, cough, or dysphagia, but has lost about 4 kg over the past two months without trying. He has smoked 20 cigarettes per day for 35 years and drinks heavily when in the community. He reports occasional burning discomfort when swallowing but no haemoptysis. He is worried he might have throat cancer.

Medications: Nil

Allergies: Nil known

Past history: Smoking, alcohol use disorder, gastro-oesophageal reflux (intermittently treated)

Social history: Long custodial sentence, no regular GP prior to custody

Examination findings: Hoarse voice, mildly erythematous oropharynx, no visible masses, no lymphadenopathy, afebrile, normal vital signs

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

Monique Fry, aged 32, presents to the prison health clinic complaining of worsening insomnia. She reports lying awake for hours, having racing thoughts, and waking frequently through the night. She denies recent substance use but has a long history of methamphetamine dependence and PTSD related to domestic violence. She has been in custody for 3 months and says sleep was initially better but has worsened over the last few weeks. She is tearful but denies current suicidal ideation. She previously used diazepam in the community but has not had any sedatives since incarceration.

Medications: Nil

Allergies: Nil known

Past history: PTSD, methamphetamine dependence (in remission), insomnia, previous self-harm

Social history: Aboriginal woman, former rough sleeper, estranged from family, no current visitors

Examination findings: Alert, cooperative, anxious affect, appears fatigued. Vitals normal. No evidence of psychosis or withdrawal.

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

Daniel Ibrahim, aged 37, presents to the prison health clinic with low mood, poor concentration, and fatigue. He has been in custody for 4 months and reports ongoing distress due to lack of contact with his children. He feels increasingly isolated and says ‘maybe they’d be better off without me’. He denies active suicidal intent but reports thoughts of self-harm and has previously cut himself while in prison. He has a history of major depressive disorder and was on sertraline in the community but stopped taking it when incarcerated.

Medications: None currently

Allergies: Nil known

Past history: Major depressive disorder, previous self-harm (no suicide attempts)

Social history: Father of two, separated from partner, no current visits or calls permitted due to court restrictions

Examination findings: Flat affect, soft voice, no psychosis or agitation. Oriented, tearful, minimal eye contact. Normal physical exam and vitals.

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

Naomi Tan, aged 41, presents to the prison health clinic with increasing shortness of breath on exertion and bilateral leg swelling. She was transferred from a regional correctional facility two weeks ago. She reports orthopnoea and waking at night breathless. She has a history of rheumatic fever as a teenager in the Northern Territory and has not had any follow-up for many years. She is a non-smoker and denies chest pain or cough. She has not been reviewed by a cardiologist in custody.

Medications: Nil

Allergies: Nil known

Past history: Rheumatic fever (age 15), no known secondary prophylaxis, no documented cardiac investigations

Social history: Aboriginal woman, grew up in rural community, multiple prior incarcerations, no consistent primary care access

Examination findings: HR 96 bpm, BP 108/64 mmHg, JVP elevated, bilateral basal crepitations, pansystolic murmur loudest at apex, pitting oedema to knees

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

Jordan McCarthy, aged 25, presents to the prison health clinic with a painful, swollen left ankle after a sports game in the prison yard. He recalls landing awkwardly while jumping and immediately felt sharp pain. He was unable to bear weight at the time but managed to limp back to his unit. The injury occurred 3 hours ago. There is no previous history of joint problems or injury to this ankle.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Serving a short sentence, otherwise well, plays regular sport

Examination findings: Moderate swelling and tenderness over the lateral malleolus, mild bruising, unable to weight-bear. No open wounds. Dorsalis pedis pulse present. Sensation intact.

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

Helen Varga, aged 59, presents to the prison clinic after noticing blood in her urine over the past two days. She reports no pain on urination, but describes passing dark red urine at the start of voiding. She denies fever, dysuria, or abdominal pain. She has had no recent trauma and is not menstruating. She is a former smoker (40 pack-years) and was recently transferred from another correctional facility. She has not had a cervical or urinary tract examination in over 10 years.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Former smoker, no regular GP, limited engagement with preventative healthcare

Examination findings: Afebrile, normotensive, abdomen soft, non-tender, no palpable masses. No flank tenderness. Urine dipstick: blood +++, nitrites – , leukocytes –

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

Isaac Fraser, aged 29, presents to the prison medical clinic with a rash on his palms and soles that has developed over the past week. He describes the rash as red, non-itchy, and not painful. He also mentions feeling more tired than usual and has noticed some swelling in his groin. On further questioning, he discloses unprotected sex with multiple partners before incarceration, including one partner with a known history of STIs. He has not had any STI screening since entering custody 2 months ago.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: History of transactional sex, previously homeless, smokes tobacco, no known drug use

Examination findings: Generalised maculopapular rash including palms and soles, bilateral inguinal lymphadenopathy, no mucosal lesions, afebrile, vitals normal

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

Travis O’Neil, aged 38, presents to the prison health unit requesting help for opioid dependence. He reports using heroin daily prior to incarceration and is experiencing cravings, poor sleep, and agitation. He has been in custody for 10 days and did not receive opioid substitution therapy (OST) on entry. He describes symptoms of early withdrawal that have now eased but says he is struggling with thoughts of using again upon release. He is serving a short sentence and expects release in 6 weeks.

Medications: Nil

Allergies: Nil known

Past history: Opioid use disorder, previous overdose, depression, hepatitis C (treated)

Social history: Homelessness, unstable housing, history of incarceration, estranged from family

Examination findings: Alert, well-nourished, mild restlessness, no current withdrawal signs. BP 124/76, HR 84, afebrile

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

Amira Saleh, aged 22, presents to the prison medical clinic with a request for pregnancy confirmation and support. She was recently transferred to a women’s correctional facility and reports a positive home pregnancy test performed the day before. Her last menstrual period was approximately 7 weeks ago. She is unsure if she wants to continue the pregnancy and feels overwhelmed. She has no known medical issues, takes no medications, and this is her first pregnancy. She expresses concern about confidentiality, possible judgement, and whether she will be forced to continue the pregnancy in prison.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Recently incarcerated, no current contact with family, no regular GP or antenatal care

Examination findings: Well appearing, normal vitals, abdomen soft and non-tender, no bleeding or pain

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

Leon Wilson, aged 44, presents to the prison clinic with increasing fatigue, dark urine, and a general sense of ‘feeling off’ for the past week. He reports occasional abdominal discomfort and reduced appetite. He was diagnosed with chronic hepatitis B infection five years ago but has not had follow-up or treatment. He was recently transferred to your facility. He drinks alcohol occasionally but denies injecting drug use. There is no jaundice noted, but he appears pale and tired.

Medications: Nil

Allergies: Nil known

Past history: Chronic hepatitis B (untreated), hypertension

Social history: Born overseas in a hepatitis B endemic country, serving a long sentence, no family contact

Examination findings: Mild hepatomegaly, no ascites, no asterixis. BP 116/72, HR 88, afebrile. No jaundice. Mild RUQ tenderness.

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

Michelle Tran, aged 36, presents to the prison health clinic with worsening headaches and blurred vision over the past month. She has a known history of poorly controlled hypertension but has not been on any regular medications since entering custody 4 weeks ago. She reports associated dizziness and occasional nausea but no vomiting or seizures. She denies trauma or recent illness. She is not taking any over-the-counter medications.

Medications: Nil currently

Allergies: Nil known

Past history: Hypertension (diagnosed 3 years ago), non-adherent to therapy in community

Social history: Vietnamese-Australian, smoker, no alcohol or drug use, previously disengaged from healthcare

Examination findings: BP 188/112 mmHg, HR 86 bpm, RR 16, Temp 36.7°C. Visual acuity reduced bilaterally, fundoscopy reveals blurred disc margins. Neurological exam otherwise normal.

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

Raymond Doyle, aged 58, presents to the prison medical clinic with new onset confusion and difficulty walking. Officers report he has been increasingly unsteady and forgetful over the past week. He has a long history of alcohol dependence and was recently transferred after spending time in segregation due to behavioural issues. He is not on any current medications. He is dishevelled, thin, and has poor dentition. There is no reported trauma.

Medications: Nil

Allergies: Nil known

Past history: Chronic alcohol use, previous hospitalisation for withdrawal, poor nutritional intake

Social history: Long-term prisoner, isolated, previous episodes of self-neglect

Examination findings: Disoriented to time and place, horizontal nystagmus, broad-based gait, unable to perform tandem walking, normal temperature, BP 130/80, HR 92 bpm

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

Angela Cooper, aged 33, presents to the prison medical clinic requesting help with smoking cessation. She has been smoking since age 14 and currently smokes 25 cigarettes per day. She says she wants to quit before her release in 3 months so she can ‘start fresh’ for her children. She has tried quitting several times in the past but relapsed due to stress. She denies current mental illness or substance use. She is open to trying ‘whatever works’ and asks for advice.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Mother of two, long smoking history, no prior engagement with smoking cessation services

Examination findings: Normal vitals, BMI 26 kg/m², clear chest, no signs of respiratory disease

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

Darren Hughes, aged 47, presents to the prison health clinic with a painful right great toe that began two days ago. He describes the pain as severe and throbbing, worse at night, and says even the bedsheet touching his toe is unbearable. He has a history of hypertension and obesity. He denies trauma and has not experienced similar symptoms before. He drinks alcohol daily when in the community but has not used illicit drugs. He has been in custody for one month.

Medications: Amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, obesity (BMI 33 kg/m²)

Social history: Alcohol use disorder, poor diet, sedentary lifestyle

Examination findings: Right first MTP joint is red, hot, swollen, and extremely tender. No overlying breaks in the skin. Afebrile. Vitals normal.

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

Matthew Reid, aged 39, presents to the prison clinic after receiving notification of a positive interferon-gamma release assay (IGRA) test during routine intake screening. He reports no cough, weight loss, fever, or night sweats. He was born in Papua New Guinea and moved to Australia at age 12. He denies known contact with anyone with active tuberculosis (TB). His chest x-ray, arranged yesterday, is reported as normal.

Medications: Nil

Allergies: Nil known

Past history: Nil significant medical history

Social history: Previously homeless, has lived in multiple states, no prior TB screening

Examination findings: Afebrile, well-appearing, normal chest exam, BMI 23 kg/m²

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

Renee McIntyre, aged 27, presents to the prison health clinic with persistent genital discharge and mild pelvic discomfort. She reports the symptoms started about 10 days ago. She denies fever, nausea, or urinary symptoms. She has had multiple sexual partners prior to incarceration and has never had a cervical screening test. She is unsure of any past STI history. She is embarrassed to discuss the symptoms and is worried others in the prison will find out.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Incarcerated 2 months ago, previously engaged in sex work, reports prior unstable housing and no consistent GP

Examination findings: Afebrile, mild lower abdominal tenderness, no rebound or guarding. No visible lesions or discharge externally. Speculum and bimanual exams not yet performed.

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

Bruce Jarrett, aged 64, presents to the prison health clinic complaining of increasing shortness of breath and a persistent cough productive of white sputum. He has smoked heavily since age 16 and reports being diagnosed with ‘chronic bronchitis’ several years ago, though he has not had any formal lung function testing. He denies chest pain, haemoptysis, or fever. He uses his cellmate’s salbutamol inhaler occasionally but has no prescribed respiratory medications.

Medications: Nil

Allergies: Nil known

Past history: Long-term smoker (50 pack-years), hypertension

Social history: Incarcerated for the past 6 months, limited physical activity, previously homeless

Examination findings: Expiratory wheeze, reduced air entry bilaterally, no cyanosis or peripheral oedema, SpO2 94% on room air, RR 18, HR 88, BP 130/78

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

Ricky Samuels, aged 31, presents to the prison health clinic with widespread itching and a red, bumpy rash that started on his wrists and has spread to his torso and groin over the past week. Several other inmates in his unit have reported similar symptoms. He describes the itch as worse at night and says scratching is affecting his sleep. He denies fever or systemic symptoms. This is his first presentation to healthcare in custody.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Sharing a cell in a crowded unit, no access to recent laundry services

Examination findings: Excoriated papules on wrists, elbows, waistband, and groin. Linear burrows seen on interdigital spaces. No secondary infection. Afebrile. Vitals normal.

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

Elaine Walker, aged 54, presents to the prison clinic with increasing urinary frequency, nocturia, and urgency over the past month. She denies dysuria or haematuria. She has had two episodes of incontinence, which she finds distressing. She has a past history of hysterectomy for fibroids and obesity. She denies fever or flank pain. She is worried about seeing a male doctor and asks for help managing her symptoms without ‘being poked and prodded’.

Medications: Amlodipine, esomeprazole

Allergies: Nil known

Past history: Obesity (BMI 36), hypertension, hysterectomy

Social history: Long sentence, previous trauma history, not engaged in regular healthcare before custody

Examination findings: Abdomen soft, non-tender. BMI 36 kg/m². External genital exam declined. No costovertebral angle tenderness. Vital signs normal.

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

Tyrell Andrews, aged 21, is brought to the prison health clinic after being found in possession of self-made tattoo equipment. On examination, he has several fresh tattoos on his forearms and chest, with visible redness, swelling, and mild discharge. He reports feeling ‘a bit sick’ and says the tattoos were done using a makeshift needle and ink from a pen. He has a history of substance use and has never been tested for blood-borne viruses (BBVs). He is concerned about getting into trouble but agrees to be assessed.

Medications: Nil

Allergies: Nil known

Past history: Cannabis use, occasional amphetamine use

Social history: Recently incarcerated, multiple tattoos done in custody, no prior BBV testing

Examination findings: Multiple inflamed tattoo sites, mild purulent discharge, no systemic signs. Temp 37.6°C, HR 90, RR 16, BP 122/74. No lymphadenopathy.

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

Nicole Baxter, aged 30, presents to the prison health clinic reporting low energy, cold intolerance, and unexplained weight gain over the past 3 months. She feels increasingly ‘foggy’ and struggles to concentrate. She was previously living on the streets and has never had regular medical care. She has no known chronic illnesses but recalls a family member with thyroid disease. She is not pregnant and denies illicit drug use or alcohol intake.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Previously homeless, estranged from family, no history of GP care

Examination findings: HR 58 bpm, BP 112/70, T 35.9°C, dry skin, delayed reflexes, mild periorbital puffiness, no goitre or neck tenderness

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

Samuel Riley, aged 43, presents to the prison health clinic complaining of chronic back pain that worsens with activity and is disrupting his sleep. He reports the pain began several years ago after a workplace injury but has worsened during his current incarceration due to limited movement and a poor mattress. He requests ‘something strong’ for the pain. He has a history of opioid dependence and was on methadone prior to custody, but it was discontinued on entry. He expresses frustration with being ‘ignored’ and feels staff assume he’s drug-seeking.

Medications: Nil currently

Allergies: Nil known

Past history: Opioid use disorder, chronic low back pain, depression

Social history: Former manual labourer, multiple incarcerations, estranged from family

Examination findings: BMI 29 kg/m², lumbar paraspinal tenderness, reduced flexion, no neurological deficits, straight leg raise negative bilaterally. Vitals normal.

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