AKT – Rural Health

Matthew Jeffries, aged 47, presents to your rural practice after injuring his right hand while using a post-hole digger on his property this morning. He reports immediate pain and swelling over the dorsum of the hand. There is no neurovascular compromise. You have limited imaging services and the local hospital is on bypass due to staffing shortages.

Past history includes hypertension and well-controlled type 2 diabetes. No medications aside from perindopril. No allergies.

On examination, there is a laceration over the 2nd metacarpal with bruising and swelling, no deformity, and preserved range of motion in all fingers. Capillary refill is < 2 sec. No foreign body is visible in the wound. You have a portable ultrasound but no X-ray available today.

What is the most appropriate next step in management?

Karen Doolan, aged 66, presents for a routine check-up in a rural town where you are the sole GP. She has a 40-pack-year smoking history and quit 5 years ago. She is otherwise well and takes no regular medications.

She asks if there is any lung cancer screening available in the bush, as she’s seen news about new programs starting.

You have limited access to advanced imaging, and the nearest CT scanner is over 200 km away. She is not enrolled in any specific programs.

What is the most appropriate response to her query?

Jimmy Walker, a 22-year-old jackaroo, presents after being bitten by a snake while repairing fencing 90 minutes from your rural clinic. He was brought in by co-workers and is now anxious, sweating, and complains of nausea. There are two fang marks on his left ankle, surrounded by mild swelling. No bandage was applied en route. Nearest hospital with antivenom is 3 hours away by road.

On examination: pulse 104 bpm, BP 138/84 mmHg, RR 22, SpO2 98% on room air. No ptosis, diplopia or bleeding observed. Urine is dark brown.

What is the most appropriate immediate management?

Susan Malcolm, aged 38, presents to your remote community clinic with a painful, hot, red area on her lower leg. She reports a recent scratch from barbed wire while working on her property. She has fevers, chills, and feels generally unwell. The clinic has limited supplies and no immediate access to imaging or pathology.

On examination: temperature 38.8°C, HR 96 bpm, BP 110/70 mmHg. The area is erythematous with poorly demarcated margins, approx. 15 cm diameter, and tender. No abscess is evident.

What is the most appropriate management?

Trevor Mullins, aged 58, presents for review of his mental health care plan. He lives in a rural area with no local psychiatrist and limited availability of mental health services. He has chronic depression, currently managed with escitalopram 20 mg daily, but reports recent worsening symptoms, poor sleep, and reduced motivation.

He denies suicidal ideation but is clearly distressed. His closest mental health nurse visits the town monthly. Trevor prefers not to travel due to financial issues.

What is the most appropriate next step in his management?

Angela Costello, aged 72, presents to your remote practice with a 3-day history of shortness of breath and cough productive of green sputum. She reports fevers and rigors. She has COPD and is on tiotropium and salbutamol. There is no local radiology service, and your oxygen concentrator is currently in use for another patient. She is saturating 91% on room air.

On examination: RR 26/min, HR 102 bpm, T 38.5°C. Auscultation reveals coarse crackles in the right lower zone. BP is 122/68 mmHg. You have access to oral and IM antibiotics and can request a RFDS transfer if needed.

What is the most appropriate next step?

Natalie Dhu, aged 29, presents with lower abdominal pain, fever and vaginal discharge in a remote Aboriginal community. She is sexually active with multiple partners and is unsure of her STI screening history. There is no local pathology collection. A pregnancy test is negative. She is febrile (38.6°C), HR 104, and there is cervical motion tenderness on bimanual exam.

What is the most appropriate next step in her management?

David Nguyen, a 63-year-old retired farmer, presents for results of a fasting glucose test (7.2 mmol/L) and HbA1c (6.7%). He is overweight and has a strong family history of type 2 diabetes. He lives 90 minutes from the nearest town with pharmacy services. He is keen to avoid medication if possible. BP today is 138/84 mmHg.

What is the most appropriate next step in management?

Rachel Keenan, aged 33, presents for antenatal care at 18 weeks gestation. She lives in a remote community and has not yet had an antenatal ultrasound. There is no local sonographer, and the next visiting service is in 4 weeks. She has no symptoms of concern and is otherwise well. You have access to basic point-of-care testing.

What is the most appropriate next step in her care?

Maurice Clay, a 71-year-old man, presents to your isolated practice with sudden onset of right-sided weakness and slurred speech 4 hours ago. There is no CT imaging locally, and no thrombolysis capacity. He is conscious and oriented, BP 176/92 mmHg, HR 84 bpm, afebrile. Your nurse is available, and you have a basic ambulance vehicle. Weather has grounded the RFDS for at least 12 hours.

What is the most appropriate immediate action?

Felicity Yamba, aged 17, presents with her mother to your rural general practice. She complains of fatigue and heavy periods. Menarche was at age 13, and her periods have always been heavy, lasting 7–9 days. She has no known medical conditions. Iron studies were ordered last visit and show: ferritin 8 µg/L (ref 30–300), Hb 104 g/L (ref 115–160), MCV 72 fL (ref 80–96).

She lives in a town with limited access to pathology and no gynaecology services. What is the most appropriate next step in her management?

Barry Kent, aged 84, presents for routine review. He lives alone on a rural property and receives Meals on Wheels. He has hypertension and mild cognitive impairment. He is independent in activities of daily living but was found wandering near his mailbox last week, confused and dehydrated. Nearest support services are 2 hours away. His daughter visits fortnightly.

What is the most appropriate next step in his care?

Leonard ‘Lenny’ Day, a 38-year-old Aboriginal man, presents with left foot pain and swelling after stepping on a nail 5 days ago. He is diabetic with poor glycaemic control and smokes daily. On examination: temperature 37.8°C, ulcer with surrounding erythema on plantar surface, foul odour, mild purulent discharge. No palpable pedal pulses. He has no current foot care provider. Nearest podiatrist is 400 km away.

What is the most appropriate next step?

Miriam Bashir, aged 29, presents during a rural locum clinic for emergency contraception. She had unprotected intercourse 5 days ago and is not using regular contraception. She is concerned as the local pharmacy is closed until next week and the next nearest service is 2 hours away. She is unsure of her cycle dates.

What is the most appropriate management?

Roger Minchin, aged 56, presents with a 6-month history of chronic low back pain in a farming community. He reports daily pain that worsens with lifting and improves with rest. There is no red flag history. He does not wish to travel for allied health services. There are no physios in town, and the internet is unreliable for telehealth physiotherapy.

What is the most appropriate management strategy?

Janelle Boyd, aged 24, presents to your rural clinic with a painful right breast lump and fever. She is 3 weeks postpartum and breastfeeding. There is no local radiology or pathology. On examination, the right breast is erythematous, warm, and tender, with a 3 cm fluctuant mass in the upper outer quadrant. She is febrile at 38.4°C and has no known allergies. Her baby is feeding from the other breast only due to pain.

What is the most appropriate next step in management?

Anthony Haines, aged 51, presents with persistent insomnia and stress after a recent drought impacted his farm. He is struggling with finances, has lost interest in usual activities, and is tearful during the consultation. He has no suicidal thoughts. He has never seen a psychologist and is reluctant to attend services in the nearby town due to stigma. There is no psychologist or counsellor in town.

What is the most appropriate next step?

Hannah Watego, aged 16, presents with a swollen, painful knee after a fall while playing netball in a remote town. You have no access to X-ray today. The joint is swollen and tender laterally with limited range of motion. She is unable to weight bear. No neurovascular deficit. The nearest imaging is 5 hours away and the next visiting GP is in one week.

What is the most appropriate next step in management?

Tommy Rankin, aged 7, presents with fever, lethargy and a widespread maculopapular rash. He is Aboriginal and lives in a remote community. His mother reports he has not had his 4-year-old vaccinations due to family relocation. He recently returned from visiting relatives in an area with a known measles outbreak. He has photophobia and a cough.

What is the most appropriate next step?

Patrick Dillon, aged 67, presents for review of his chronic obstructive pulmonary disease (COPD) in a small rural practice. He has had two exacerbations in the past year requiring oral steroids and antibiotics. He continues to smoke 5–10 cigarettes per day. Spirometry confirms moderate COPD. He is using tiotropium and salbutamol. The nearest pulmonary rehab program is 3 hours away. He is reluctant to quit smoking.

What is the most appropriate next step in his management?

Lisa Tran, aged 41, presents with recurrent episodes of epigastric pain in a rural clinic. She describes a gnawing pain relieved by food and antacids. The pain has recurred every few months over the past year. There is no access to endoscopy locally, and H. pylori stool antigen testing is unavailable. She has no alarm features and is otherwise well.

What is the most appropriate next step?

Mark Wilton, aged 62, is a retired miner presenting with a chronic productive cough and exertional dyspnoea. He lives in a rural town and smoked 30 pack-years, quitting 10 years ago. You suspect occupational lung disease. There is no local access to specialist respiratory services or spirometry. CXR shows bilateral interstitial changes.

What is the most appropriate next step?

Chloe Morris, aged 27, presents for preconception counselling in a small town with no maternity hospital. She has type 1 diabetes, well-controlled on insulin pump therapy. She asks about pregnancy options. The nearest regional hospital with obstetric services is 5 hours away. She is keen to stay in her community if possible.

What is the most appropriate advice?

Benji Gordon, aged 8, presents with fatigue and pallor in a remote community clinic. He has been eating soil from the garden, and his diet is low in meat. You suspect iron deficiency anaemia. Full blood count and iron studies are unavailable. There is no pharmacist in town and infrequent visiting paediatric services.

What is the most appropriate next step?

Gregory Pike, aged 74, presents with unintentional weight loss and progressive dysphagia to solids, then liquids. He lives in a remote region and has no local endoscopy services. He has not seen a doctor in many years and is visibly cachectic. There is no vomiting or haematemesis.

What is the most appropriate next step?

Denise Fogarty, aged 59, presents with worsening breathlessness and leg swelling in a rural town. She has a history of hypertension and is on perindopril. She reports needing multiple pillows to sleep and feels tired walking to the letterbox. There is no local echocardiography or cardiology service. On examination, she has bilateral basal crackles and pitting oedema to the knees. BP is 160/92 mmHg, HR 88 bpm, SpO2 94% on room air.

What is the most appropriate next step?

Sarah Hughes, aged 35, presents with dysuria, frequency, and suprapubic pain in a small rural clinic. She is 22 weeks pregnant. She has no fever or flank pain. You have no onsite laboratory, but MSU was collected and sent for culture. Dipstick today shows nitrites and leucocytes. She has no known allergies.

What is the most appropriate next step?

Thomas Bindi, aged 15, presents with a 3-day history of fever, headache, and a purpuric rash. He lives in a remote Aboriginal community. On examination, he is febrile at 39.5°C, has a non-blanching rash on both legs and arms, and appears lethargic. There is no local pathology or hospital.

What is the most appropriate immediate management?

Mary Holloway, aged 82, presents with a laceration to her shin after a fall in her garden. She takes aspirin and rivaroxaban for atrial fibrillation. She lives 2 hours from the nearest emergency department. The wound is 5 cm long, not actively bleeding, and appears clean. You have basic suturing and dressing supplies but no diathermy or sutures for deep layers.

What is the most appropriate management?

Kaleb Rowan, aged 19, presents with scrotal pain and swelling for 12 hours in a remote clinic. He reports nausea but no trauma. Examination reveals a tender, swollen left testicle with high-riding position and absent cremasteric reflex. There is no local ultrasound access or surgical services.

What is the most appropriate next step?

Helen Marshall, aged 61, presents for follow-up after being treated for community-acquired pneumonia 6 weeks ago. She lives in a rural area with limited access to imaging. She is now asymptomatic. A follow-up chest X-ray was arranged but she could not attend due to flood-related road closures. She is an ex-smoker with a 25-pack-year history.

What is the most appropriate next step in her care?

Pauline Jensen, aged 28, presents to your remote general practice with a 3-month history of generalised fatigue and joint pain. She also notes some facial rash appearing after sun exposure. You suspect a connective tissue disease. There is no local access to pathology or rheumatology services.

What is the most appropriate next step?

Brian Wallace, aged 73, presents to your rural clinic with new-onset urinary incontinence and unsteadiness when walking. His daughter notes he has become more forgetful over the last few months. There is no fever, dysuria or back pain. Your clinic has no CT scanner and limited specialist access. Neurological exam reveals a broad-based gait and mild confusion.

What is the most appropriate next step?

Rebecca Lang, aged 22, presents for Implanon insertion in a small community clinic. She has a history of vasovagal episodes during previous procedures. You are the only health practitioner present and have no nurse support. Emergency services are over an hour away. The clinic has basic resuscitation equipment.

What is the most appropriate next step?

Geoffrey Ryan, aged 69, presents with a history of a chronic non-healing ulcer on his lower left leg. He is a former smoker with a history of ischaemic heart disease. The ulcer is shallow, with irregular borders and minimal exudate. Peripheral pulses are diminished on examination. He lives 300 km from a vascular service. ABI is 0.6 in the affected leg.

What is the most appropriate next step?

Shelley Grant, aged 47, presents with right upper quadrant pain and nausea in your remote clinic. She has no fever or jaundice. On examination, she is tender in the RUQ with a positive Murphy’s sign. There is no access to ultrasound locally, and the nearest imaging service is 6 hours away. She has a normal white cell count and LFTs are unavailable.

What is the most appropriate next step?

Daniela Moretti, aged 5, presents with her father for a school entry check. She lives in a rural area and has not previously been assessed for hearing. Her father reports she often asks for repetition and has delayed speech. You do not have access to audiometry but have a tuning fork and otoscope available.

What is the most appropriate next step?

Leonie Brack, aged 38, presents with ongoing fatigue and low mood. She has a history of postpartum depression and now has 3 young children. She lives in a rural community and has no access to local mental health services. She scores 18 on a DASS-21. There is no safety risk identified.

What is the most appropriate management option?

Jack Flynn, aged 56, presents with ongoing alcohol dependence and poor glycaemic control. He lives in a remote Aboriginal community and has failed multiple previous attempts at abstinence. His HbA1c is 9.8%, and he frequently misses meals. There are no local detox facilities. He is willing to try again but is reluctant to leave his community.

What is the most appropriate initial intervention?

Naomi Lee, aged 30, presents with concerns about possible domestic violence. She lives on a remote station and has limited phone access. She discloses controlling behaviour, verbal abuse and isolation by her partner. There is no nearby women’s shelter, and she is frightened to leave. She has no physical injuries.

What is the most appropriate immediate action?

Corey Adams, aged 19, presents with weight loss, polydipsia, and fatigue in a small rural practice. He has recently returned from working on a remote cattle station. Capillary BGL is 24 mmol/L and urine dipstick reveals ketones and glucose. He appears clinically dry but is alert and oriented. The nearest hospital is 4 hours away and retrieval services are delayed due to weather.

What is the most appropriate immediate management?

Wendy Tomlins, aged 45, presents to your rural clinic with recurrent headaches. She describes a dull bilateral ache worse in the evenings, associated with jaw clenching. She is a school principal under high stress. She has no focal neurological signs, nausea, vomiting or visual symptoms. There is no access to CT or MRI locally.

What is the most appropriate initial management?

Mickie Dorr, aged 3, is brought to your rural clinic with a 2-day history of wheezing and increased work of breathing. He has no known asthma diagnosis. His mother reports a viral illness last week. On examination, he has an audible wheeze, subcostal recession, and SpO2 of 94% on room air. There is no fever. Salbutamol via spacer is available at the clinic.

What is the most appropriate immediate management?

Ethan Fraser, aged 27, presents to your rural clinic for review of a dog bite sustained while working on a sheep station. He was bitten on the hand 6 hours ago. There is a puncture wound and swelling, but no purulence or systemic signs. He is unsure of the dog’s vaccination status. He has not had a tetanus booster in over 10 years.

What is the most appropriate next step in management?

Alison Kerr, aged 33, presents during a rural women’s health clinic for cervical screening. Her last Pap smear was 6 years ago. She is asymptomatic. She is unsure of her HPV vaccination status. She is monogamous and not pregnant. The clinic uses self-collected HPV testing as an option. There is no local gynaecology service.

What is the most appropriate screening approach?

Tom Riley, aged 62, presents with persistent knee pain after years of working on farms. He has bilateral crepitus and morning stiffness lasting less than 30 minutes. You suspect osteoarthritis. He lives 4 hours from the nearest imaging centre. He has no red flag features. You have access to basic analgesia and limited allied health.

What is the most appropriate initial management?

Isabel Torres, aged 14, presents to your rural clinic accompanied by her aunt. She discloses that she is pregnant and is uncertain about continuing the pregnancy. Her parents are not aware. She appears well and is approximately 8 weeks gestation by LMP. There is no local obstetric or mental health service.

What is the most appropriate next step?

Arthur Namatjira, aged 71, presents with dry eyes and increasing thirst in a remote Aboriginal community. He has long-standing hypertension and is on perindopril. Random BGL in clinic is 18.6 mmol/L. HbA1c from a recent visit was 8.4%. He has no symptoms of infection. There is limited access to pathology and no local diabetes educator.

What is the most appropriate management?

Lauren Bishop, aged 34, presents with fatigue and difficulty concentrating in your rural practice. She has a 6-month-old baby and reports that she is vegan. You note pallor and brittle nails. FBC shows Hb 95 g/L, MCV 105 fL. B12 and folate tests are unavailable locally.

What is the most appropriate next step?

Peter Knowles, aged 49, presents with a 2-week history of persistent cough and fatigue. He returned from PNG 3 months ago where he worked in a mining camp. He is afebrile but has lost weight. There is no haemoptysis. CXR shows cavitary lesion in the right upper lobe. Sputum sample has been collected. You are practising in a rural town with a large Indigenous population.

What is the most appropriate immediate action?