AKT – Population health (Preventative)

Emily Patterson, aged 23, presents for a general check-up and cervical screening. She is sexually active, has had three lifetime partners, and is up to date with all childhood vaccinations. Her last Pap smear was five years ago, before the change to HPV testing.

She is well and has no symptoms. She is not currently pregnant. There is no family history of cervical cancer. She does not smoke. She asks what tests she is due for.

On examination, her BMI is 22, BP is 114/72 and physical examination is normal.

What is the most appropriate next step?

Ahmed Saeed, aged 52, presents for a health check. He is asymptomatic and has no past medical history. He does not smoke, drinks alcohol occasionally, and exercises three times per week. His father died of a heart attack at 60. He is interested in knowing his cardiovascular risk.

On examination: BP 138/86 mmHg, BMI 28. Fasting lipids: TC 5.5, HDL 1.0, LDL 3.8, triglycerides 1.8. Fasting glucose is 5.4 mmol/L.

He has not had any previous cardiovascular events or diabetes.

What is the most appropriate next step?

Margaret Woods, aged 68, presents to discuss cancer screening. She is in good health and has never had bowel cancer screening. She has no symptoms and no family history of colorectal cancer.

She has had regular mammograms, cervical screening ceased at age 65, and she takes no regular medications.

She is unsure whether she needs to do anything further at her age.

What is the most appropriate advice?

Joshua Freeman, aged 17, presents for a routine check-up before starting work in aged care. He has completed all routine childhood vaccinations. He is otherwise well. He has no significant past medical history. There is no documentation of hepatitis B vaccination or serology.

He does not use recreational drugs and denies sexual activity. He is unsure if he received hepatitis B vaccine as a baby.

What is the most appropriate next step?

Ruth Kennedy, aged 45, presents for a routine check-up. She mentions her mother was recently diagnosed with osteoporosis. Ruth has no personal history of fractures or risk factors, is a non-smoker, drinks alcohol occasionally, and has a BMI of 23.

She has regular menses and is physically active. She has not had a bone density scan before and asks whether she should have one.

What is the most appropriate management?

Jason Lau, aged 35, attends for a general health check. He is a non-smoker, drinks 2–3 standard drinks on weekends, and has no chronic conditions. He works as a FIFO (fly-in fly-out) worker in mining. He reports feeling stressed at work but has no current mental health concerns.

He has not had any recent preventive health assessments and asks if anything is recommended at his age.

On examination: BP 126/80 mmHg, BMI 26, HR 76 bpm. All within normal limits.

What is the most appropriate preventive service to offer?

Ava Reynolds, aged 6, presents with her mother for a school immunisation form. Her immunisation record is incomplete. Her mother states they moved from overseas two years ago, and Ava has only had some vaccines in infancy. She is otherwise healthy and has no chronic illness.

You review her Australian Immunisation Register record and confirm she has not received any Australian-scheduled vaccines.

What is the most appropriate next step?

George Petropoulos, aged 78, presents for his annual flu vaccine. He mentions he has not received any other vaccines since retirement. He has well-controlled hypertension and osteoarthritis. He lives at home and is independent with activities of daily living.

He asks if there are any other vaccines he should be receiving at his age.

On review of the Australian Immunisation Handbook, he has not received pneumococcal or shingles vaccines.

What vaccines should be recommended today?

Layla Chan, aged 29, is 10 weeks pregnant with her first child. She is generally well and is receiving shared antenatal care. She works as a childcare worker and has not received any recent vaccinations. Her serology shows she is non-immune to rubella.

She is concerned about the risk of infections at work and asks what vaccines are recommended during pregnancy.

What is the most appropriate vaccination strategy now?

Trevor Singh, aged 50, is an Aboriginal man attending for a chronic disease review. He is known to have type 2 diabetes and hypertension. He is currently stable, takes his medications regularly, and does not smoke. He last had a health assessment four years ago.

You review his record and note no evidence of a recent 715 Health Assessment.

What is the most appropriate next step?

Fiona Riley, aged 33, presents for pre-conception counselling. She and her partner are planning to start trying for a baby in the next 3 months. She is otherwise healthy and takes no regular medications. Her immunisation history is unclear, and she is unsure about rubella immunity.

She asks what health checks and preparations are appropriate before pregnancy.

On examination: BMI 24, BP 118/70, non-smoker, moderate alcohol use socially.

What is the most appropriate next step?

Connor Walsh, aged 21, presents for a catch-up health check. He is an apprentice chef, recently moved out of home. He has a history of mild asthma. He has never had a skin check and has fair skin with a few moles. He has noticed one new darker spot on his back.

He has no family history of melanoma but often works outdoors. He wears a hat but rarely uses sunscreen.

What is the most appropriate advice regarding melanoma prevention?

Joanne Nguyen, aged 62, presents for a health review. She has a history of hypertension and well-controlled type 2 diabetes. She is up to date with routine bloods and retinal screening. She asks if she needs any cancer screening. She has not had a mammogram for over 5 years.

She has no breast symptoms and no family history of breast or ovarian cancer.

What is the most appropriate next step?

Riley Martin, aged 5, presents with his mother for his first year of school health check. He is generally well with no developmental concerns. His vaccinations are up to date. His mother is concerned about hearing and vision as he often sits close to the TV.

There is no history of recurrent ear infections, and his speech is appropriate for age.

What is the most appropriate screening assessment at this visit?

Susan Horvath, aged 48, is a new patient attending for a check-up. She has no significant past medical history and does not take any regular medications. She is a non-smoker, BMI 26, and drinks 1–2 glasses of wine most nights. She has not seen a doctor for over 5 years.

You discuss alcohol intake with her and she is surprised to hear it may be considered excessive.

What is the most appropriate tool to assess her alcohol use?

Leonard Griggs, aged 82, presents with his daughter for a general check-up. He lives alone and is independent with ADLs. He had a fall 3 months ago but was uninjured. He is not on any sedative medications. His BP today is 132/78 mmHg and he has mild peripheral neuropathy from type 2 diabetes.

His daughter is concerned about another fall.

What is the most appropriate next step in falls prevention?

Jasmine Thomas, aged 43, presents for a general health review. She is a single mother of two and has not had any medical care in several years. She has smoked 10 cigarettes per day since age 19. She is otherwise well. BP 118/76 mmHg, BMI 23, no chronic disease.

She is not ready to quit smoking but is open to information.

What is the most appropriate intervention at this stage?

Noah Ibrahim, aged 12, is brought in by his mother for a routine check-up. He is healthy, enjoys school, and has no significant medical history. His mother is concerned about his weight. His BMI is at the 92nd percentile for age, consistent with overweight. He is not bullied and is socially well connected.

Diet consists mostly of home-cooked meals, but portion sizes are large. He plays video games most afternoons.

What is the most appropriate initial management?

Daniel O’Keefe, aged 47, presents for advice after his workplace offered a voluntary PSA test. He is asymptomatic and has no family history of prostate cancer. He has read conflicting information online and is unsure whether he should have the test.

He requests your recommendation.

What is the most appropriate approach?

Maya Fernandes, aged 38, presents for a travel consultation. She plans to visit family in India for 6 weeks with her 2-year-old daughter. Maya migrated to Australia 10 years ago and last visited India 3 years ago. Her daughter has completed routine vaccinations.

They will be staying with family in a rural area.

What is the most appropriate next step for the child?

Sophie Day, aged 27, presents to discuss family planning. She is considering pregnancy in the next year and asks about genetic carrier screening. Her partner is of Ashkenazi Jewish descent, and she has a cousin with cystic fibrosis. Neither has had any prior testing.

Both are healthy and have no children. They want to know what’s available.

What is the most appropriate recommendation?

Aaron Wallace, aged 56, presents for a routine check. He has a 30-pack-year smoking history but quit 6 years ago. He has no respiratory symptoms. His father died of lung cancer at age 60. Aaron is concerned about whether he should be screened for lung cancer.

He is otherwise well with no chronic disease.

What is the most appropriate management?

Emily Nguyen, aged 3, is brought in by her parents for a routine childhood immunisation. They recently moved from Victoria to Queensland and want to ensure her vaccinations are up to date. She previously received two MMR doses but no varicella vaccine. There is no history of chickenpox.

What is the most appropriate management?

Michael Tan, aged 38, works in construction and presents for a tetanus booster. He cannot recall when he last had one. He had a nail injury 2 days ago but cleaned it well and it is healing. His immunisation history is incomplete. There are no signs of infection.

What is the most appropriate management?

Natalie Russo, aged 66, attends for her flu vaccine and asks about shingles vaccination. She received the live Zostavax vaccine at age 63. She has heard about a new shingles vaccine and wants to know if she needs it too.

She is otherwise well with no immunocompromise. Her Zostavax record is confirmed in the AIR.

What is the most appropriate advice?

Jessica Tang, aged 31, presents for her first antenatal visit at 8 weeks gestation. She is G1P0. She follows a vegetarian diet and takes a daily multivitamin. Her BMI is 21 and blood pressure is normal. She has no past medical issues. She asks about recommended antenatal screening tests.

What is the most appropriate next step?

Pauline Davis, aged 74, presents for a health review. She is independent and lives with her husband. She has mild osteoarthritis and hypertension. She has not had any cognitive testing before but has recently forgotten names and missed appointments. MMSE is 26/30 today.

She remains independent with ADLs and has insight into the memory changes.

What is the most appropriate next step?

Thomas Eldridge, aged 45, is a long-distance truck driver attending for a general health check. He has not seen a doctor in years. He is a current smoker, BMI 29, and drinks 4–5 beers most nights. He denies any symptoms. BP is 140/88 mmHg, pulse 82 regular.

He asks about a health assessment for his age group.

What is the most appropriate preventive service to offer?

Layla Abdullah, aged 59, is a refugee from Syria who arrived in Australia 18 months ago. She is attending for a general health check. She is illiterate in English and Arabic and relies on her son for communication. There is no prior documentation of vaccination, and she has no regular medications.

What is the most appropriate first step in her preventative healthcare?

Benji Walters, aged 16, presents with his mother to discuss acne but mentions he is feeling increasingly down, especially after school. He has withdrawn from his soccer team and says he’s ‘tired of everything’. He denies suicidal thoughts but seems flat. His mother is unaware of these feelings.

What is the most appropriate next step?

Harold Mason, aged 76, presents with his daughter for a check-up. He has type 2 diabetes and chronic kidney disease stage 3a. He lives alone and takes medications independently. His daughter asks whether he should still be driving, as he recently got lost coming home.

On examination, Harold is oriented to person but unsure of the date and has minor difficulty recalling recent events.

What is the most appropriate next step?

Zara Patel, aged 44, is an Aboriginal woman attending for a health check. She has no chronic conditions and takes no regular medication. She has not seen a GP in over 5 years. She has three children and helps care for her elderly mother.

She is unsure about recommended screenings and assessments for her age and background.

What is the most appropriate service to offer today?

Frankie Lim, aged 36, presents for a check-up. He is a man who has sex with men (MSM) and is in a non-monogamous relationship. He uses condoms inconsistently. He has no symptoms and last had an STI screen 12 months ago. He has not been vaccinated for HPV or hepatitis A/B.

What is the most appropriate management today?

Angela Brown, aged 29, presents after a needlestick injury while volunteering at a music festival. She was stuck by a discarded needle while picking up rubbish. She is unsure of her hepatitis B immunity status and believes she was vaccinated in childhood.

What is the most appropriate next step?

Diego Marquez, aged 61, presents for a routine check-up. He has no chronic conditions and is a non-smoker. He has not seen a GP in over 10 years. He is unsure if he has ever had a bowel cancer screen and asks whether he is due for anything.

There is no family history of colorectal cancer. He has no symptoms.

What is the most appropriate next step?

Sandra Leung, aged 70, presents for a routine health check. She is generally well and independent. She has not had a hearing test in over 20 years. She does not wear hearing aids but notes that sometimes it is hard to hear conversations in noisy places.

She asks whether she should get her hearing checked.

What is the most appropriate next step?

James O’Donnell, aged 40, presents for a general health check. He works in IT and leads a sedentary lifestyle. He has a family history of type 2 diabetes (mother diagnosed at 52). He is asymptomatic but concerned about prevention.

On examination: BMI 31, BP 124/82 mmHg. No other abnormalities.

What is the most appropriate initial investigation?

Ruby Edwards, aged 58, presents to establish care after relocating. She is healthy and has no significant medical history. She had a Pap smear at age 51 but is unsure about further cervical screening. She has no symptoms and is in a monogamous relationship.

What is the most appropriate next step?

Leo Zhang, aged 8, presents with his father for a routine check. His father mentions that Leo has been struggling with reading at school. Vision screening was not done at school due to illness. There is no history of eye disease, and Leo is otherwise well.

What is the most appropriate next step?

Amira Hassan, aged 34, is a new patient who recently arrived from Somalia. She is pregnant (G2P1) at 14 weeks. She speaks limited English and attends with her husband. You confirm with an interpreter that she has not previously received antenatal care in Australia.

What is the most important first screening test to arrange?

Charlie Watson, aged 54, is a long-term smoker who presents for review. He has a 35 pack-year smoking history and is considering quitting. He has tried to quit twice before using patches, but relapsed. He is motivated but says cravings are very strong in the morning.

What is the most appropriate pharmacological option to offer?

Emma Johnston, aged 49, presents for routine screening. She is up to date with cervical and breast screening. Her mother had a hip fracture at age 72. Emma has no other risk factors for osteoporosis. She is postmenopausal and asks whether she should have a bone density test.

What is the most appropriate advice?

Priya Mehta, aged 32, presents for contraceptive advice. She is sexually active with one partner and not planning pregnancy soon. She has not had a cervical screen for over 6 years and is unsure when it’s due. She had a normal Pap smear previously.

What is the most appropriate next step?

Samira Khan, aged 28, presents at 36 weeks’ gestation. She has had no complications and is booked for shared antenatal care. She is unsure about vaccinations in late pregnancy and asks if there is anything due.

She received the influenza vaccine earlier in pregnancy.

What is the most appropriate vaccination recommendation now?

George Lin, aged 67, presents for follow-up after his recent diagnosis of hypertension. He has no other medical conditions. He is a non-smoker and drinks 1–2 glasses of wine with dinner. His BMI is 27. He asks if any screening is needed now that he is over 65.

He has never been screened for abdominal aortic aneurysm (AAA).

What is the most appropriate management?

Mohammed Saleh, aged 42, is a new patient attending for a check-up. He recently migrated from Afghanistan. He is unsure of his vaccination history but believes he had some childhood vaccines. He has no current symptoms and is not immunocompromised.

What is the most appropriate next step?

Emily Bishop, aged 22, presents for a travel consult before backpacking through Southeast Asia for 4 months. She is healthy, takes no medications, and is up to date with routine Australian vaccines. She will be visiting rural areas and staying in hostels.

What is the most appropriate next step?

Sarah Aldridge, aged 46, presents for discussion of breast cancer risk. Her sister was diagnosed with breast cancer at 39. Their mother is well, and there is no known BRCA mutation in the family. Sarah is well and has no breast symptoms.

She is concerned about her own risk and whether she needs earlier screening.

What is the most appropriate next step?

Markus Hill, aged 60, is a teacher presenting for a flu vaccine. He mentions he gets frequent colds from students and asks about other vaccines he may be eligible for. He is up to date with tetanus boosters and has no chronic medical conditions.

What is the most appropriate additional vaccine to offer?

Hannah Bell, aged 30, presents for a mental health review. She has a history of major depression, currently stable on sertraline. She is interested in reducing medication and asks about non-pharmacological strategies. She works full time and has a supportive partner.

What is the most evidence-based recommendation to support relapse prevention?