KFP – Military and veteran health

Samuel Rogers, aged 41, is a former ADF member who presents to your clinic in a regional town requesting a renewal of his medication scripts. He reports increasing difficulty with sleep and frequent nightmares. He also mentions that he has been drinking more in the evenings to ‘take the edge off’ and avoid disturbing dreams. He was medically discharged five years ago after a deployment to Afghanistan and has since worked intermittently as a security contractor. Samuel lives alone and does not have regular contact with family. He denies suicidal ideation but admits to thoughts of ‘just disappearing’ sometimes. He was diagnosed with PTSD by Defence and is under DVA care. He was last reviewed by a psychiatrist 9 months ago, and has not attended any recent counselling appointments. He is currently on sertraline 100 mg daily but has not taken it for several weeks.

Medications: Sertraline 100 mg daily (non-compliant last 3 weeks)

Past history: PTSD (diagnosed 4 years ago), alcohol use disorder (intermittent binge pattern), mild TBI (2015)

Social history: Lives alone, unemployed, socially isolated, ex-ADF

Psychiatric history: History of trauma-related nightmares, hypervigilance, and avoidance behaviour

Examination findings: Appears tired, guarded but cooperative. No perceptual disturbance or disordered thought. PHQ-9 score: 19, AUDIT-C: 7

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

Angela Whittaker, a 32-year-old Army reservist, presents for a review of ongoing fatigue, poor concentration, and menstrual irregularities. She reports experiencing these symptoms for over 6 months, worsening after her last deployment which ended 12 months ago. Angela also complains of dry skin, increased cold sensitivity, and low mood. She describes persistent anxiety, difficulty coping with routine stressors, and occasional panic episodes. She has continued to fulfil her duties as a reservist but finds it increasingly difficult. Her medical history includes polycystic ovary syndrome (PCOS) and an episode of post-natal depression three years ago. She takes no regular medications and denies substance use. She uses a long-acting reversible contraceptive (LARC) for contraception.

Medications: Etonogestrel implant

Past history: PCOS, post-natal depression

Family history: Mother has hypothyroidism and type 2 diabetes

Social history: Lives with husband and two young children; works part-time in administration; actively involved in Army Reserve duties

Examination findings: Mild facial puffiness, dry skin, HR 56 bpm, BP 102/66 mmHg, BMI 30. No goitre, reflexes slightly delayed. PHQ-9 score 14. No clinical signs of anaemia.

Investigations:

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

Leonard ‘Len’ Murray, a 78-year-old Navy veteran, presents for a routine check-up. He has a history of ischaemic heart disease, hypertension, and osteoarthritis. His main concern today is increasing difficulty with hearing conversations, especially when there is background noise. His wife reports that he often turns the television up too loud and frequently asks people to repeat themselves. Len served as a diesel mechanic on naval ships for over 25 years and recalls many years of working without hearing protection. He denies vertigo, tinnitus, or recent ear infections. He uses no ototoxic medications and has not had any recent head trauma.

Medications: Perindopril 5 mg daily, aspirin 100 mg daily, paracetamol SR 665 mg TDS

Past history: IHD with stent placement 10 years ago, hypertension, OA knees and hands

Social history: Retired, lives with wife, active in local RSL and Men’s Shed

Examination findings: Otoscopy: bilateral intact tympanic membranes, no wax. Whispered voice test: impaired bilaterally. Rinne: air > bone bilaterally. Weber: midline.

Investigations: [Insert Image Here]

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

Dominic Kelly, a 52-year-old former infantry soldier, presents with persistent low back pain that has worsened over the past six months. He reports a long-standing history of intermittent back pain since a parachute training injury in his early 30s, but the pain is now constant and interferes with sleep and daily activities. He has trialled physiotherapy, massage, and over-the-counter analgesics with minimal relief. He has not worked in the past year due to pain and is receiving a DVA pension. Dominic also describes ‘pins and needles’ in his left foot and occasional numbness radiating from his buttock down the leg. There is no bowel or bladder disturbance.

Medications: Paracetamol SR 665 mg TDS, ibuprofen 400 mg PRN, fish oil

Past history: Parachute injury, chronic low back pain, osteoarthritis (lumbar), PTSD

Social history: Lives with partner, non-smoker, walks with a stick, former ADF infantry

Examination findings: Mild lumbar scoliosis, reduced lumbar flexion. Straight leg raise (SLR) elicits pain at 40° on left. Normal power, reflexes, and sensation in lower limbs. Gait slow but steady.

Investigations: Lumbar spine X-ray: moderate L4-L5 facet joint degeneration, no fracture or spondylolisthesis.

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

Nathan Bell, a 27-year-old serving ADF member, presents with new-onset tremor, palpitations, weight loss, and anxiety over the past two months. He states that he has been sleeping poorly and has had increased irritability and difficulty concentrating during training exercises. He denies stimulant use. He has no significant past medical history and takes no regular medications. There is a family history of autoimmune thyroid disease (his sister has Graves’ disease). On examination, he has a fine tremor, warm moist hands, HR 112 bpm (regular), BP 138/72 mmHg. There is a visible goitre with bruit on auscultation. Reflexes are brisk and there is mild lid lag.

Medications: None

Past history: Nil significant

Family history: Graves’ disease (sister)

Social history: Lives in barracks, undergoing ADF training, no alcohol or recreational drugs

Examination findings: Fine tremor, mild exophthalmos, diffuse goitre with bruit, sinus tachycardia, brisk reflexes

Investigations:

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

Emily Sanderson, a 35-year-old former RAAF flight crew member, presents with episodic shortness of breath, chest tightness, and dry cough, particularly during exercise or when exposed to cold air. These symptoms have become more frequent since moving to a colder climate 4 months ago. She reports a previous diagnosis of exercise-induced bronchospasm (EIB) during active service, but this was not formally investigated. She is otherwise healthy and takes no regular medications. She has no history of smoking and denies any current infections or systemic symptoms. Emily is now working in a civilian role and is interested in returning to regular running and cycling.

Medications: Nil

Past history: Suspected exercise-induced bronchospasm, seasonal allergic rhinitis

Family history: Brother with asthma

Social history: Former flight crew, now working in aviation administration; non-smoker, lives with partner

Examination findings: Normal chest auscultation at rest, no wheeze. Peak expiratory flow (PEF) 480 L/min (predicted 500 L/min). No signs of infection or systemic illness.

Investigations: Baseline spirometry: FEV1 2.9 L (80% predicted), FVC 3.6 L (85% predicted), FEV1/FVC ratio 0.81. Methacholine challenge test: Positive (20% drop in FEV1 at low dose)

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

Trevor O’Donnell, a 63-year-old Vietnam veteran, presents with symptoms of increasing forgetfulness, difficulty finding words, and occasional disorientation over the past year. His partner reports that he sometimes gets lost on familiar walks and has been more irritable and withdrawn. Trevor served in an infantry role and had prolonged exposure to Agent Orange. He has a history of PTSD and hypertension. There is no known family history of dementia. He is independent in daily tasks but has made some recent financial errors. He drinks two standard drinks most nights and stopped smoking 10 years ago. There are no hallucinations or motor symptoms.

Medications: Perindopril 5 mg daily, sertraline 50 mg daily

Past history: PTSD, hypertension, hearing loss (service-related)

Social history: Lives with partner, independent with ADLs, attends local RSL events irregularly

Examination findings: MMSE 24/30 (poor recall, reduced attention), normal gait, no focal neurology, BP 138/82 mmHg

Investigations:

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

Jacob Elridge, a 45-year-old former Army logistics officer, presents with severe pain in his right shoulder and upper arm, along with tingling and numbness in his right hand. These symptoms began gradually and have worsened over the past month. He describes the pain as constant, burning, and aggravated by light touch or movement. Jacob had a right shoulder dislocation during service 12 years ago, which required surgical repair. He has a history of PTSD and is currently unemployed. He takes prescribed analgesia but says the pain ‘feels different’ from his old injury pain. He also notes swelling and changes in skin colour and temperature in the affected limb.

Medications: Paracetamol 1 g QID, codeine/paracetamol 30/500 mg PRN

Past history: Right shoulder reconstruction (post-dislocation), PTSD, chronic pain

Social history: Lives alone, supported by DVA income support, socially withdrawn

Examination findings: Right upper limb shows mild swelling, shiny skin, decreased hair growth. Allodynia present to light touch, reduced active range of motion due to pain. Pulses intact. No objective neurological deficit on motor or sensory testing. No signs of infection or systemic illness.

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

Linda Thorne, a 29-year-old ADF medic currently posted in a remote base, presents via telehealth with a 3-week history of insomnia, poor appetite, and feelings of guilt following a recent traumatic event during deployment. She discloses witnessing the death of a civilian while providing emergency care and has since experienced recurring nightmares and hypervigilance. She states, ‘I can’t stop thinking about it’ and avoids going near the medical treatment area. She denies suicidal thoughts but reports a sense of emotional numbing and detachment from colleagues. Her partner, also serving, has encouraged her to speak with someone. She has no psychiatric history and takes no regular medications.

Medications: None

Past history: Nil significant

Family history: Mother with generalised anxiety disorder

Social history: Currently serving, no children, in a relationship, based in remote Northern Territory

Examination findings (via telehealth): Appears tense, tearful during session, avoids eye contact. Speech is coherent, mood low, affect restricted. No psychosis or suicidal ideation.

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

Mark Reynolds, a 57-year-old former RAAF technician, presents with persistent chronic cough, wheeze, and exertional dyspnoea. He reports a history of exposure to aircraft fuel vapours, hydraulic fluid aerosols, and frequent use of industrial cleaning agents during his 20 years of service. He has smoked intermittently (5 pack-years) but quit 15 years ago. His symptoms have progressively worsened over the last year, and he now experiences breathlessness when walking more than 100 metres. He denies chest pain, weight loss, or haemoptysis. He has had no recent infections.

Medications: Salbutamol PRN (infrequent use)

Past history: Hypertension, mild allergic rhinitis

Family history: Father with COPD, mother with asthma

Social history: Retired, lives with spouse, former aircraft technician

Examination findings: Mild expiratory wheeze on auscultation, no cyanosis or clubbing. SpO2 96% on room air. No peripheral oedema.

Investigations: Spirometry: FEV1 62% predicted, FVC 79% predicted, FEV1/FVC ratio 0.61 (post-bronchodilator change: +5%). CXR: hyperinflated lungs, no consolidation or mass. Blood eosinophils: 0.2 x10^9/L (NR 0.0–0.5)

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

Amira Saleh, a 33-year-old ADF Army captain, presents to your clinic for advice on pregnancy planning. She has recently married and is hoping to conceive within the next 3–6 months. Amira has a well-controlled history of epilepsy, with no seizures in the past 4 years. She is currently taking sodium valproate 400 mg BD, prescribed during service before better treatment options were available. She is concerned about how her medication may affect pregnancy, as several colleagues have raised concerns. She otherwise feels well and is not taking any other medications or supplements.

Medications: Sodium valproate 400 mg BD

Past history: Epilepsy (diagnosed age 18, generalised tonic-clonic seizures), controlled on current therapy

Family history: Nil significant

Social history: Serving ADF officer, lives with husband in Defence housing, non-smoker, does not drink alcohol

Examination findings: Normal general and neurological exam. BP 116/72 mmHg, BMI 23.2

Investigations: Recent bloods: Normal renal, liver, and folate levels. No recent imaging or specialist review.

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

Steven Holloway, a 66-year-old former submariner, presents with increasing fatigue, persistent lower limb paraesthesia, and unsteady gait over the last 6 months. He reports difficulty with fine motor tasks and frequent tripping. He served in the Navy for over 20 years and spent extended periods on nuclear-powered submarines. He consumes 3–4 alcoholic drinks most nights and eats a basic diet, often skipping breakfast. He denies weight loss or bowel changes but describes occasional diarrhoea. His medical history includes hypertension and BPH.

Medications: Tamsulosin 0.4 mg daily, amlodipine 5 mg daily

Past history: Hypertension, benign prostatic hyperplasia

Social history: Retired, lives alone, poor diet, low physical activity

Examination findings: Pale, mildly ataxic gait. Reduced pinprick and vibration sense in feet. Positive Romberg. Reflexes reduced at ankles. No cranial nerve deficits. Cognition intact.

Investigations: CBC: Hb 112 g/L (130–180), MCV 106 fL (80–96), WBC and platelets normal. B12: 115 pmol/L (NR: 150–700). Folate: normal. TSH: normal. Anti-intrinsic factor antibodies: Positive

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

Melissa Tran, a 39-year-old former RAAF airfield defence guard, presents with persistent pelvic pain, dyspareunia, and dysmenorrhoea that has progressively worsened over the past year. She describes deep aching pelvic discomfort that worsens before and during menstruation, along with bloating and fatigue. Melissa completed her service five years ago and has since struggled with chronic pain and difficulty accessing consistent care due to relocation and financial stress. She has a past history of sexual assault during service and was diagnosed with PTSD two years ago. She has not been sexually active for over a year due to pain and low mood. She is currently unemployed and supported through a DVA incapacity payment.

Medications: Sertraline 100 mg daily, paracetamol PRN

Past history: PTSD (service-related), suspected endometriosis, chronic pelvic pain

Social history: Lives alone, avoids social contact, no children, not currently in a relationship

Examination findings: Mild tenderness in lower abdomen on deep palpation, no masses palpable. Pelvic exam declined. No neurological deficit. Mood appears low; flat affect.

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

Peter Ramsay, a 61-year-old retired infantry soldier, presents to your clinic with increasing daytime sleepiness, loud snoring reported by his partner, and morning headaches. He describes waking unrefreshed and struggling to stay awake during the day, sometimes dozing off while reading or watching TV. His partner is concerned about pauses in his breathing during the night. Peter’s symptoms have been present for over a year and have worsened with recent weight gain. He served in multiple deployments during his military career and was diagnosed with PTSD five years ago, currently well-managed with medication. He has a BMI of 33 and a thick neck. He consumes 1–2 standard drinks most evenings and denies smoking.

Medications: Sertraline 50 mg daily, amlodipine 5 mg daily

Past history: PTSD (stable), hypertension

Social history: Lives with partner, former ADF, retired, decreased physical activity

Examination findings: BP 142/88 mmHg, BMI 33, neck circumference 44 cm, crowded oropharynx, no goitre

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

Karen Muldoon, a 50-year-old ex-serving ADF member, presents to your clinic with chronic gastrointestinal symptoms including bloating, alternating constipation and diarrhoea, and lower abdominal discomfort. These symptoms have been ongoing for over 12 months, worsened during periods of stress, and impact her daily activities. Karen also experiences significant fatigue and brain fog. She reports that her symptoms began after a deployment to the Middle East 10 years ago, during which she had multiple episodes of gastroenteritis. She has a service-related diagnosis of PTSD, for which she sees a psychologist regularly. She is concerned about possible food intolerances and has trialled gluten and dairy elimination with inconsistent benefit.

Medications: Sertraline 100 mg daily

Past history: PTSD, deployment-related gastroenteritis, vitamin D deficiency

Social history: Lives with spouse, works part-time, eats a varied diet, moderate coffee intake

Examination findings: Abdomen soft, non-tender, no masses, no hepatosplenomegaly, normal bowel sounds. No weight loss. Vitals stable.

Investigations: FBC, CRP, coeliac serology, thyroid function tests — all normal. Faecal calprotectin: <50 ug/g (normal)

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

Thomas ‘Tom’ Gallagher, a 47-year-old former ADF engineer, presents with worsening joint pain in both hands and wrists over the past 9 months. He reports morning stiffness lasting over an hour and difficulty with tasks like gripping tools or opening jars. He has noticed swelling around the small joints of his hands and occasional low-grade fevers. He served in the Army for 22 years, including postings to cold, damp environments, and was exposed to industrial solvents and oils. There is no personal or family history of autoimmune disease. He is otherwise healthy, except for long-standing mild depression.

Medications: Sertraline 50 mg daily

Past history: Mild depression, no previous musculoskeletal conditions

Social history: Lives with wife and children, currently working in manual labour role, non-smoker, low alcohol intake

Examination findings: Bilateral MCP and PIP joint swelling, tenderness, decreased grip strength, no nodules. No skin rash, no ocular symptoms. Normal vitals. No spinal involvement.

Investigations:

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

James Easton, a 74-year-old Vietnam veteran, presents for review of recent episodes of urinary urgency, nocturia (3–4 times/night), and occasional urge incontinence. He reports a gradual decline in bladder control over the past year. He also describes chronic lower back pain and some numbness in both feet. James served as a field engineer during the Vietnam War and was exposed to Agent Orange. His medical history includes type 2 diabetes (well controlled), benign prostatic hyperplasia (BPH), and PTSD. He lives with his wife and is otherwise independent in daily activities.

Medications: Metformin 1000 mg BD, tamsulosin 0.4 mg daily, sertraline 50 mg daily

Past history: Type 2 diabetes, BPH, PTSD

Social history: Retired, ex-smoker, low alcohol intake, exercises daily

Examination findings: Lower limb reflexes reduced bilaterally, vibration sense decreased in feet. Abdomen soft, no masses. Bladder scan post-void residual: 120 mL. No signs of infection.

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

Rebecca Hughes, a 31-year-old serving Navy officer, presents to your clinic following a needle stick injury sustained while administering first aid during a shipboard incident. She reports that the needle had been used on another crew member with known intravenous drug use history and no confirmed blood-borne virus testing. The incident occurred 1 hour ago. Rebecca is distressed and wants to know her risks and next steps. She has no significant past medical history, is up to date with vaccinations including hepatitis B, and has no known allergies.

Medications: Nil

Past history: Nil significant

Social history: Serving Navy officer, monogamous relationship, no recreational drug use

Examination findings: Clean puncture wound on left index finger, bleeding encouraged and area washed thoroughly. No signs of infection. Vitals normal.

Investigations: Baseline serology sent for HIV, hepatitis B, and hepatitis C. Source patient currently untested and awaiting consent for screening.

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

David Lin, a 40-year-old former ADF artillery operator, presents with worsening bilateral tinnitus and gradual hearing loss. He describes a high-pitched ringing in both ears that is most noticeable at night or in quiet environments. He also reports difficulty following conversations in noisy settings and says this has affected his ability to work in customer service since discharge. He served for 12 years and was regularly exposed to loud weaponry without consistent use of hearing protection early in his career. He has no history of head trauma, ear infections, or ototoxic medications.

Medications: Nil

Past history: Nil significant

Social history: Lives with partner, employed part-time, non-smoker, occasional alcohol

Examination findings: Otoscopy: normal tympanic membranes bilaterally, no wax. Rinne: air > bone bilaterally. Weber: midline. No neurological deficits.

Investigations: Audiometry: bilateral high-frequency sensorineural hearing loss consistent with noise-induced hearing loss (NIHL)

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

Stephanie North, a 36-year-old serving Army logistics officer, presents with intermittent palpitations, fatigue, and reduced exercise tolerance over the past two months. She reports episodes of rapid heartbeat, sometimes accompanied by light-headedness but no syncope. Symptoms are more frequent during physical exertion and periods of high stress. Her medical history includes anxiety and iron deficiency anaemia. She completed a deployment in the Pacific 9 months ago. She takes a combined oral contraceptive and reports regular menstrual cycles. She denies caffeine overuse or stimulant use.

Medications: Ethinylestradiol/levonorgestrel daily, oral iron supplements

Past history: Iron deficiency anaemia, generalised anxiety disorder

Social history: Active-duty officer, exercises 4–5 times/week, non-smoker, moderate alcohol intake

Examination findings: BP 114/72 mmHg, HR 102 bpm (resting), ECG shows frequent PACs, no other abnormalities. No murmur. Cap refill <2s. No signs of heart failure or thyroid disease.

Investigations: Hb: 118 g/L (NR 120–160), Ferritin: 15 µg/L (NR 30–300), TSH: 2.1 mIU/L (NR 0.4–4.0), Electrolytes and renal function: normal

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

Michael Doukas, a 55-year-old ex-ADF combat medic, presents with ongoing alcohol dependence. He drinks 6–8 standard drinks daily and reports that attempts to reduce intake have failed due to irritability, poor sleep, and tremors. He retired from service 10 years ago and was previously deployed to East Timor and Iraq. He reports symptoms of PTSD, including nightmares and hypervigilance, and says that alcohol helps him ‘switch off’. He has tried counselling in the past but found it unhelpful. He has no history of seizures or liver disease, but recent blood tests show mildly elevated liver enzymes. He is not currently on any pharmacotherapy. He lives alone and has limited social contact.

Medications: Nil

Past history: PTSD, hyperlipidaemia, alcohol use disorder

Social history: Lives alone, ex-smoker, not working, DVA Gold Card holder

Examination findings: BP 144/86 mmHg, HR 96 bpm, mild tremor, no jaundice or ascites. MoCA: 25/30. No focal neurological signs.

Investigations: LFTs: ALT 78 U/L (NR <50), GGT 156 U/L (NR <60), AST 92 U/L (NR <50). MCV: 102 fL (NR 80–96). INR, bilirubin and albumin normal.

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

Lisa Carmichael, a 28-year-old full-time Army combat engineer, presents for review of a 4-month history of persistent right knee pain. The pain began during an intensive field exercise and has been aggravated by running, stair climbing, and kneeling. She reports swelling after long periods of weight-bearing, and occasional locking sensations. There is no history of acute trauma, instability, or systemic symptoms. Lisa is otherwise fit and well, and has no prior knee injuries. She is currently unable to complete physical fitness requirements for her role and is concerned about her deployability status.

Medications: Ibuprofen PRN

Past history: Nil significant

Social history: Lives on base, highly active, non-smoker, no alcohol use

Examination findings: Right knee: mild effusion, medial joint line tenderness, pain on McMurray’s test. No ligamentous laxity. Full passive range of motion, pain on deep flexion. No signs of infection.

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

Anthony Wallace, a 69-year-old Vietnam veteran, presents with worsening short-term memory, sleep disturbance, and social withdrawal over the past 6 months. His wife reports he becomes irritable and startled easily, especially by loud noises or when approached from behind. He has frequent nightmares and avoids ANZAC Day events, which he previously attended. He denies hallucinations but describes feeling ‘on edge all the time’. He has a past history of untreated PTSD and drinks 3–4 beers most nights to help him sleep. He has no history of head injury or neurological disease. He has not seen a psychologist or psychiatrist in over 20 years.

Medications: Nil

Past history: PTSD (service-related, undermanaged), hypercholesterolaemia

Social history: Retired, lives with wife, limited social support, DVA Gold Card holder

Examination findings: Alert, oriented, speech normal. Affect blunted, startled by hallway noise. MMSE 27/30. No focal neurology. Vitals normal.

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

Emily Ng, a 26-year-old currently serving Air Force communications technician, presents requesting support for gender-affirming care. She was assigned male at birth and has socially transitioned over the past year, including name and pronoun change. Emily is seeking medical transition options and is unsure how to proceed within the ADF system. She has been experiencing increasing distress related to gender dysphoria and reports ongoing low mood but no suicidality. She is otherwise well, with no significant past medical history, and has not yet commenced hormonal treatment.

Medications: Nil

Past history: Nil significant

Social history: Lives in Defence accommodation, good support from peers, not currently partnered, non-smoker

Examination findings: Normal male secondary sex characteristics. Normal vitals. PHQ-9 score: 11 (mild-moderate depression)

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

Paul Redman, a 62-year-old retired infantry officer, presents with persistent lower limb swelling and skin discolouration over the past 9 months. He reports heaviness and aching in both legs, particularly at the end of the day. On examination, he has bilateral pitting oedema to mid-calf, hyperpigmentation around the ankles, and mild varicosities. He recalls sustaining a left leg shrapnel injury during deployment in Timor 25 years ago, requiring surgical repair and extended immobilisation. He has no history of heart failure, renal or liver disease. He is otherwise well, walks daily, and is not on any regular medications.

Medications: Nil

Past history: Remote left leg trauma with surgery, hypertension (resolved with lifestyle changes)

Social history: Lives with partner, non-smoker, no alcohol intake, maintains active lifestyle

Examination findings: Bilateral pitting oedema (left > right), hemosiderin staining, lipodermatosclerosis, varicose veins. Peripheral pulses present. No ulceration or signs of infection.

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

Neil Armstrong, a 48-year-old currently serving logistics officer, presents with a 3-week history of persistent fatigue, mild exertional dyspnoea, and palpitations. He reports recent deployment to a tropical region and recalls a febrile illness with muscle aches two months ago, which resolved spontaneously. Since then, he has struggled to regain his usual fitness and notes an increased resting heart rate. He denies chest pain, orthopnoea, or ankle swelling. No cough or wheeze. He has no past medical history and takes no medications. He has resumed light physical training but cannot complete usual running drills.

Medications: Nil

Past history: Nil significant

Social history: Active-duty officer, based in northern Australia, non-smoker, occasional alcohol

Examination findings: HR 94 bpm, BP 118/74 mmHg, mild tachycardia, no murmurs or peripheral oedema. Lungs clear. No rash or joint swelling. ECG: sinus rhythm, no ST changes

Investigations: FBC, UEC, TSH normal. Troponin I mildly elevated. CXR normal. Echocardiogram: mild global LV dysfunction, LVEF 45%

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

Isobel Atkinson, a 44-year-old ex-ADF helicopter crew member, presents with frequent headaches, difficulty concentrating, poor sleep, and a sensation of imbalance. She reports two concussive incidents during service — one from a helicopter hard landing and another from being thrown during a training simulation. Since her discharge 3 years ago, she has struggled with irritability, memory lapses, and fatigue. She denies current mood disorder but admits to frustration and emotional lability. She has not worked since discharge and receives DVA income support. She has had normal brain CT and no seizures.

Medications: Nil

Past history: Two concussions during service, no psychiatric history, no seizures

Social history: Lives with spouse, limited social activity, no alcohol, ex-smoker

Examination findings: Alert, oriented, mild difficulty with short-term memory recall on MOCA (24/30). Normal gait. No focal neurological signs. Hearing intact.

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

Clare Whiting, a 33-year-old former Army transport driver, presents with chronic neck and upper back pain. She describes persistent dull pain with intermittent sharp flares radiating to her shoulders, worse after long periods of sitting or lifting. Her symptoms began after a road traffic accident during deployment 5 years ago, where she sustained a whiplash injury. She has attended multiple physiotherapy sessions with some benefit but reports limited improvement. She is currently unemployed and reports sleep disturbance and low mood but no suicidal ideation. She has a current DVA White Card for the neck injury and is unsure what further support is available.

Medications: Paracetamol PRN, occasional ibuprofen

Past history: Chronic musculoskeletal pain, whiplash injury (service-related), low mood

Social history: Lives with partner, not working, reduced physical activity, previously very active

Examination findings: Reduced cervical range of motion, tenderness over paraspinal muscles, no focal neurological signs. Spurling’s test negative. No red flags.

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

Samuel King, a 59-year-old retired Navy diver, presents with ongoing symptoms of dizziness, intermittent tinnitus, and a sensation of ear fullness, particularly when changing position. He reports that symptoms began during his last year of service and have persisted since discharge. He denies vertigo or true spinning sensation but notes difficulty maintaining balance when turning quickly or walking in the dark. He reports no hearing loss or facial weakness. His diving medical history includes several deep dives and one episode of barotrauma 15 years ago. He has a DVA Gold Card and is concerned his condition may be service-related.

Medications: Atorvastatin 20 mg daily

Past history: Hypercholesterolaemia, one past barotrauma event during service

Social history: Retired, active, no alcohol, non-smoker

Examination findings: Weber: midline. Rinne: air > bone bilaterally. No nystagmus. Romberg: mildly positive. Dix-Hallpike: negative. Gait slow but steady. No cranial nerve deficits.

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

Angela Muir, a 52-year-old retired RAAF avionics technician, presents with increasing hand stiffness and difficulty with fine motor tasks such as buttoning shirts and typing. She reports the symptoms began gradually over the last year and are worse in the morning. She also notes tightness in her face and hands and increasing sensitivity to cold weather, where her fingers turn pale and painful. She served for 20 years in aircraft hangars with frequent exposure to solvents and fuel vapours. She denies joint swelling or red eye but mentions occasional acid reflux and dry mouth. She is concerned about an autoimmune condition.

Medications: Pantoprazole 20 mg daily

Past history: GORD, no prior rheumatological disease

Social history: Lives alone, no alcohol, ex-smoker, retired on DVA Gold Card

Examination findings: Thickened skin on hands and face, sclerodactyly, reduced oral aperture, Raynaud’s phenomenon evident on exposure to cold. Nailfold capillaroscopy shows dilated capillaries and dropout.

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

Jason O’Connor, a 39-year-old former Army combat engineer, presents with chronic low mood, poor sleep, and decreased libido. He reports ongoing fatigue despite 8–9 hours of sleep, low motivation, and difficulty concentrating. These symptoms have persisted for over 12 months. Jason was medically discharged 3 years ago due to orthopaedic injuries. He also notes reduced shaving frequency and recent weight gain. There is no history of depression, but he describes a lack of ‘drive’ and worsening physical fitness. He is not currently on any medication. He enquires whether his testosterone could be low.

Medications: Nil

Past history: Medically discharged post-orthopaedic injury, chronic pain, ex-smoker

Social history: Lives with partner, low physical activity, moderate alcohol intake

Examination findings: BMI 31, decreased muscle bulk, reduced testicular volume, no gynaecomastia. BP 124/80 mmHg, HR 68 bpm

Investigations: Morning testosterone: 6.1 nmol/L (NR 8.3–30.2), LH: elevated, FSH: elevated. SHBG normal. TSH, cortisol, and prolactin normal.

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

Rachel Tomlinson, a 41-year-old former Army communications operator, presents with a 3-month history of non-specific abdominal discomfort, bloating, and loose stools. She describes cramping and urgency after meals, with occasional episodes of nocturnal diarrhoea. She completed two deployments in the Middle East and was medically discharged 5 years ago for PTSD. She recalls having severe gastroenteritis during her first deployment but has not had any recent infections. She is concerned about bowel cancer but denies bleeding or weight loss. She has not seen a gastroenterologist and is unsure if her condition is service-related.

Medications: Sertraline 100 mg daily

Past history: PTSD (service-related), past deployment-related enteric infection

Social history: Lives alone, limited social support, eats take-away frequently, ex-smoker, drinks alcohol occasionally

Examination findings: Soft, non-tender abdomen, no masses, no hepatosplenomegaly. No perianal findings. Normal vitals.

Investigations: FBC normal, CRP normal, coeliac serology negative, faecal calprotectin 80 μg/g (NR <50), stool culture negative

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

Douglas “Doug” Perkins, a 74-year-old Vietnam veteran, presents with progressive shortness of breath over 12 months. He describes dyspnoea on exertion, a dry cough, and reduced exercise capacity. He denies chest pain, wheeze, or haemoptysis. He reports a 25-pack-year smoking history but quit 20 years ago. He worked as a field engineer and recalls exposure to dust and asbestos during bunker construction in Vietnam. He has no history of asthma or heart disease. His DVA Gold Card was recently approved for service-related musculoskeletal issues.

Medications: Nil

Past history: Osteoarthritis, hyperlipidaemia

Social history: Lives with wife, retired, maintains garden but reduced stamina

Examination findings: RR 18, SpO2 96% RA, fine bibasal crackles, no wheeze, no clubbing. Heart sounds dual, no murmurs. No peripheral oedema.

Investigations: CXR: Reticular changes at bases, no consolidation. Spirometry: Restrictive pattern. DLCO reduced. ESR normal.

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

Jessica Walters, a 29-year-old active-duty Army medic, presents with persistent pelvic pain and painful periods since returning from deployment 6 months ago. She describes deep, dull pelvic discomfort that worsens during menstruation and interferes with her ability to perform physical duties. She also reports dyspareunia and occasional bowel discomfort around her period. She is otherwise well, with no history of STIs, PID, or recent infections. Her periods are regular. She is currently sexually active with one partner and uses condoms for contraception. She has not had prior abdominal surgery. She is seeking advice regarding her symptoms and impact on her operational readiness.

Medications: Nil

Past history: Nil significant

Social history: Lives on base, highly active, non-smoker, moderate alcohol intake

Examination findings: Mild tenderness on deep palpation in the suprapubic region. No masses. Pelvic exam declined. No fever or vaginal discharge. Normal vitals.

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

Matthew Crowe, a 66-year-old Vietnam veteran, presents with worsening nightmares, insomnia, and emotional numbness. He reports that recent national commemorations have triggered intrusive memories and distressing flashbacks. He describes avoiding social events and feels estranged from family. He denies suicidal ideation but reports increasing irritability and episodes of anger. He was diagnosed with PTSD in the 1990s but disengaged from therapy years ago. He has no current mental health care plan and does not recall the last time he spoke to a counsellor. He is on a DVA Gold Card and seeks support to manage his symptoms again.

Medications: Nil

Past history: PTSD (service-related), hypertension (well controlled)

Social history: Divorced, lives alone, limited social contact, ex-smoker

Examination findings: Appears anxious, guarded. No signs of psychosis. MOCA: 27/30. No neurological deficit. BP 126/80 mmHg.

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

Linda Costello, a 35-year-old Royal Australian Navy supply officer, presents for review after being diagnosed with gestational diabetes mellitus (GDM) at 26 weeks gestation. She is currently serving and is concerned about how the diagnosis may affect her duties and antenatal care while on base. This is her first pregnancy, and she reports feeling well aside from fatigue. Her OGTT showed a fasting glucose of 5.4 mmol/L and 2-hour glucose of 9.1 mmol/L. She has no significant past medical history. She is otherwise healthy and has a BMI of 29 kg/m².

Medications: Pregnancy multivitamin

Past history: Nil significant

Social history: Lives on Defence housing, non-smoker, no alcohol, active role within base logistics

Examination findings: BP 122/78 mmHg, HR 86 bpm, fundal height appropriate for gestational age, no oedema or proteinuria

Investigations: OGTT: Fasting 5.4 mmol/L (NR <5.1), 2-hour glucose 9.1 mmol/L (NR <8.5)

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

Benjamin Hayes, a 45-year-old recently discharged ADF member, presents with worsening sleep disturbance, hypervigilance, and headaches. He recently relocated from a rural posting and is struggling to adjust to civilian life. He reports frequent nightmares, difficulty falling asleep, and being easily startled by noises. He avoids crowded areas and describes intrusive thoughts about his last deployment. He admits to drinking 6–8 standard drinks most nights to help him sleep. He has no current mental health supports in place, though he has a DVA White Card for service-related PTSD.

Medications: Nil

Past history: PTSD (service-related), alcohol use, no major physical illness

Social history: Lives alone, recently unemployed, limited social support, ex-smoker

Examination findings: Appears tired, restless. BP 138/82 mmHg. MOCA 28/30. No focal neurology. No suicidal ideation expressed but appears distressed when discussing military experiences.

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

Emily Ferguson, a 26-year-old active-duty Navy physical training instructor, presents with amenorrhoea for the past 5 months. She reports high levels of physical activity, including twice-daily workouts and preparation for an advanced fitness course. She denies pregnancy, uses no contraception, and reports fatigue and increased stress. She has a history of irregular cycles and was previously diagnosed with iron deficiency. She has no signs of androgen excess, and denies eating disorders, but reports reduced appetite and being ‘too busy to eat properly’. Her BMI is 19 kg/m².

Medications: Ferrous sulfate as needed

Past history: Iron deficiency, irregular menses

Social history: Lives on base, non-smoker, low alcohol intake, intense exercise schedule

Examination findings: Vitals normal. Slim build. No acne or hirsutism. Breast and pelvic exam unremarkable. No thyroid enlargement.

Investigations: bHCG negative. FSH low, LH low, estradiol low. TSH, prolactin, cortisol all within normal range. Ferritin: 18 µg/L (NR 30–300)

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

Dean Marshall, a 62-year-old retired Army tank crewman, presents with progressive hearing difficulties and ringing in both ears. He first noticed difficulty following conversations in noisy environments and now struggles with phone calls and group settings. He served for over 20 years with significant exposure to engine and weapon noise, particularly in armoured vehicles, and reports inconsistent use of hearing protection. He denies vertigo or otalgia. He holds a DVA Gold Card but has not previously sought hearing-related support.

Medications: Atorvastatin 20 mg daily

Past history: Hypertension, hyperlipidaemia

Social history: Lives with spouse, retired, non-smoker, low alcohol use

Examination findings: Otoscopy normal bilaterally. Weber test: midline. Rinne test: air > bone bilaterally. No cranial nerve abnormalities. No signs of infection or cerumen impaction.

Investigations: Pure tone audiogram: bilateral symmetrical high-frequency sensorineural hearing loss. Tympanometry: normal middle ear pressure and compliance.

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

Simone De Luca, a 30-year-old Army intelligence analyst, presents with increasing fatigue, palpitations, and light-headedness during PT sessions. She recently returned from deployment in Southeast Asia and reports intermittent diarrhoea, bloating, and poor appetite during the trip, which she attributed to local food. She has since lost 5 kg unintentionally. She has a history of iron deficiency and had previously been treated with oral iron. She has resumed menstruation post-deployment but feels unusually weak despite rest. No signs of bleeding are reported.

Medications: None

Past history: Iron deficiency (previously corrected), no other chronic illness

Social history: Non-smoker, no alcohol, vegetarian, lives on base

Examination findings: Pale conjunctivae, HR 98 bpm, BP 104/70 mmHg, soft abdomen, no masses, no peripheral oedema. Mild postural drop. Cardiovascular exam otherwise unremarkable.

Investigations: Hb 93 g/L (NR 120–160), MCV 74 fL (NR 80–96), Ferritin 8 µg/L (NR 30–300), CRP normal. Coeliac serology positive (anti-tTG IgA). Iron studies: low iron and transferrin saturation. B12, folate, and thyroid function normal.

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

Graham Fielding, a 69-year-old retired RAAF ground crew technician, presents with progressive exertional dyspnoea, dry cough, and reduced exercise tolerance. He has a 30-pack-year smoking history but quit 15 years ago. He reports long-term exposure to aircraft fuels, solvents, and maintenance-related fumes during his 20-year service. He denies chest pain or orthopnoea. He is concerned about his breathlessness worsening over the last year. He holds a DVA Gold Card for service-related musculoskeletal injuries but has not claimed for respiratory issues.

Medications: Salbutamol PRN

Past history: Osteoarthritis, hypercholesterolaemia

Social history: Lives with wife, retired, walks daily but now limited to 200m due to breathlessness

Examination findings: RR 20, SpO2 94% RA, fine inspiratory crackles at both lung bases. No peripheral oedema or clubbing. Cardiovascular exam normal.

Investigations: Spirometry: FEV1/FVC 0.78, FVC reduced, DLCO reduced. CXR: bibasal reticulonodular changes. CRP normal.

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

Stephanie Rangi, a 31-year-old Aboriginal former ADF combat medic, presents for review 2 months post-discharge. She reports persistent fatigue, poor appetite, and intermittent low-grade fever. She completed her final deployment 6 months ago and was exposed to unsanitary conditions and limited access to medical facilities during her posting. Since returning, she has experienced night sweats, malaise, and unintentional weight loss of 6 kg. She denies cough, urinary symptoms, or gastrointestinal complaints. She has no known chronic medical conditions and does not smoke or drink alcohol.

Medications: Nil

Past history: Nil significant

Social history: Returned to remote community post-discharge, unemployed, limited access to healthcare services

Examination findings: Temp 37.8°C, HR 92 bpm, BP 112/72 mmHg. Mild cervical lymphadenopathy, no hepatosplenomegaly. Lungs clear. No rash or joint swelling.

Investigations: FBC: Hb 104 g/L (NR 120–160), WCC 6.2 x10⁹/L, Platelets 360 x10⁹/L. ESR 48 mm/hr, CRP 22 mg/L. LFTs: mildly elevated ALT/AST. HIV negative. TB Quantiferon positive. CXR: mild hilar lymphadenopathy, no consolidation.

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

Daniel Wu, a 38-year-old ex-ADF aviation technician, presents with chronic right shoulder pain and weakness, which he attributes to repetitive lifting and overhead work during his service. He was medically discharged 2 years ago and now works part-time in manual labour. He reports difficulty lifting his arm above shoulder height, disturbed sleep due to shoulder discomfort, and occasional clicking. There is no history of acute trauma. He holds a DVA White Card for accepted musculoskeletal conditions.

Medications: Ibuprofen PRN

Past history: Chronic rotator cuff tendinopathy (service-related), mild depression

Social history: Lives with partner, non-smoker, moderate alcohol intake

Examination findings: Tenderness over greater tuberosity, positive Hawkins-Kennedy and empty can tests. Reduced active range of motion, preserved passive range. No swelling or instability.

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

Amira Khan, a 34-year-old Army signals officer, presents with new-onset urinary urgency, frequency, and occasional nocturia. She denies dysuria, incontinence, or haematuria. Symptoms have gradually developed over the past three months. She is otherwise fit and well, with no significant past medical history. She notes increased workplace stress due to recent promotion and reports restricting fluid intake during field operations. She has had two uncomplicated vaginal deliveries. She is sexually active with one partner and uses a hormonal IUD. There is no history of UTIs or pelvic surgery.

Medications: Levonorgestrel IUD

Past history: Nil significant

Social history: Lives on base, active duty, non-smoker, low alcohol intake

Examination findings: Abdomen soft, non-tender. No suprapubic or CVA tenderness. Pelvic exam: no prolapse, normal vaginal mucosa. Bladder scan: 40 mL post-void residual. Urine dipstick: negative for nitrites, leucocytes, and blood.

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

Trevor McAllister, a 72-year-old Vietnam veteran, presents with progressive memory problems, difficulty managing finances, and increasing irritability. His wife reports he often misplaces items, repeats questions, and struggles with planning tasks. He remains independent in personal care but has withdrawn from social activities. He was exposed to Agent Orange during his deployment. He has a DVA Gold Card for accepted musculoskeletal injuries. There is no history of stroke, alcohol misuse, or psychiatric illness.

Medications: Atorvastatin 40 mg daily, irbesartan 150 mg daily

Past history: Hypertension, hyperlipidaemia

Social history: Lives with wife, retired, no alcohol or smoking

Examination findings: Alert, oriented to person but not date. MOCA: 21/30. Gait normal. No focal neurological signs. BP 138/84 mmHg. Weight stable.

Investigations: FBC, UEC, LFTs, B12, folate, TSH all within normal limits. CT brain: mild generalised cerebral atrophy, no infarct or mass.

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

Lucas Brennan, a 37-year-old former Army logistics corporal, presents with persistent back pain and difficulty concentrating. He reports chronic lower back pain since lifting injuries sustained during training exercises. He was medically discharged 3 years ago and now works intermittently in a warehouse role. He reports sleep disturbance, anxiety, and ‘brain fog’, which he attributes to poor sleep and constant pain. He holds a DVA White Card for chronic musculoskeletal pain. He has been using over-the-counter codeine-ibuprofen preparations daily for several years.

Medications: Codeine/ibuprofen combination PRN (self-managed)

Past history: Chronic low back pain (service-related), intermittent anxiety, no surgery

Social history: Lives alone, low physical activity, ex-smoker, high caffeine intake

Examination findings: BMI 28. Mild lumbar paraspinal tenderness. Normal neurological exam. Straight leg raise negative. No red flags identified. MOCA: 26/30.

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

Oliver Greenwood, a 28-year-old serving Army combat engineer, presents following a recent on-base incident in which he lost consciousness for 2–3 minutes after a blast during a training exercise. He was assessed in hospital and cleared of acute injury. Since then, he has had difficulty concentrating, feels irritable, and experiences intermittent headaches and dizziness. His partner reports he’s more withdrawn and easily startled. He denies suicidal ideation but reports feeling ‘foggy’ and exhausted after minimal mental effort. He is concerned about being medically downgraded.

Medications: Nil

Past history: Nil significant

Social history: Lives on base, no alcohol or smoking, highly active prior to incident

Examination findings: Vitals normal. GCS 15. No focal neurological signs. MOCA: 25/30. Romberg negative. Cranial nerves intact. Mild photophobia reported. CT brain (day of incident): normal.

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

Chloe Martin, a 33-year-old former Navy communications officer, presents with ongoing fatigue, low mood, and nonspecific joint pain. She was medically discharged 18 months ago due to persistent symptoms following COVID-19 infection acquired during overseas deployment. She describes ‘brain fog’, headaches, palpitations, and reduced exercise tolerance. These symptoms fluctuate, worsened by exertion. She denies chest pain or shortness of breath at rest. Basic bloods including FBC, thyroid function, and iron studies were previously normal. She has been unable to return to work and is receiving DVA White Card support for post-viral syndrome.

Medications: None

Past history: COVID-19 (service-acquired), medically discharged

Social history: Lives with partner, previously active, now minimal physical activity

Examination findings: Vitals normal. Alert, oriented. No focal neurology. Mild postural tachycardia noted. Joint exam unremarkable. ECG: sinus rhythm, no abnormalities.

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

Shaun Teague, a 55-year-old retired ADF infantry officer, presents for a routine check-up and expresses concern about increasing forgetfulness, irritability, and disturbed sleep. He has also noticed worsening tinnitus and difficulty concentrating. His wife reports that he often mishears her, and he is easily startled by loud noises. Shaun served in multiple deployments with exposure to gunfire, explosives, and prolonged stress. He was previously diagnosed with PTSD but has not engaged in therapy recently. He has a DVA Gold Card.

Medications: None

Past history: PTSD (service-related), hearing loss (service-related)

Social history: Lives with spouse, limited social interaction, non-smoker, occasional alcohol

Examination findings: Vitals normal. Mood mildly anxious. Hearing impaired on conversation. MOCA: 24/30. Cranial nerves intact. No focal neurology. Weber: midline, Rinne: air > bone bilaterally.

Investigations: Audiometry confirms bilateral high-frequency sensorineural hearing loss. TSH, B12, folate, and glucose normal. No red flags.

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

Isla Thompson, a 25-year-old serving Navy electronic technician, presents with persistent chest tightness, shortness of breath during exertion, and wheeze. Symptoms are worse during early morning drills and have increased over the past six months. She denies nocturnal symptoms but reports needing to stop running on base due to breathlessness. She has no history of asthma but was exposed to engine fumes and dust while working in enclosed mechanical compartments. She denies smoking. She is concerned about her ability to complete physical fitness assessments.

Medications: Nil

Past history: Nil

Social history: Lives on ship, fit and active, no alcohol or smoking

Examination findings: Vitals normal. Widespread expiratory wheeze. No clubbing or cyanosis. Normal heart sounds.

Investigations: Spirometry: FEV1 72% predicted, FVC 88%, FEV1/FVC 0.65. Post-bronchodilator FEV1 improves by 16%. CXR: normal.

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