Even after a thorough examination it can be difficult to distinguish a normal penile anatomical variant from pathology needing treatment. The common practice of treating any penile lump as a wart is no longer useful in the era of human papillomavirus (HPV) vaccination.

A Mediterranean man, aged 67 years, presented with a 6 month history of facial discolouration and photosensitivity. He had a past history of hypertension and atrial fibrillation, and was taking amiodarone 100 mg/day (commenced over 2 years ago) and enalapril 20 mg/day.

Physical examination revealed a blue-grey discolouration to his nose, cheeks and lips, sparing the periocular area and the deep skin folds (Figure 1). Further full dermatological and ophthalmic examination was unremarkable. 

DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.

Charles Reynolds Brown

I have personally had the chance to reflect on the value of work recently. The opportunity for a few weeks extra leave presented itself and seemed too good to pass up. I had a lovely time: ticking jobs off the ‘to do’ list, catching up with friends, attending some further education courses. But there were times towards the end of the month that I found myself slightly adrift. The pantry cupboard was tidy, the jasmine was pruned and I felt a creeping sense of melancholy.

Health related absenteeism is an easily understandable concept of not attending work when ill and certifying absenteeism episodes is core business for general practice. The related concept of presenteeism is relatively new and subject to numerous definitions (Table 1). In the clinical literature, presenteeism has traditionally been defined in terms of the economic impact of working when sick, that is, the lost productivity that arises from continuing to work when unwell. This lost productivity can include performance issues such as not meeting deadlines, difficulty in concentrating, not being able to think clearly, making mistakes and not being able to carry out the physical requirements of a job (eg. lifting).¹

Immunoglobulins are protein molecules. They contain antibody activity and are produced by the terminal cells of B-cell differentiation known as ‘plasma cells’. There are five classes of immunoglobulin (Ig): IgG, IgM, IgA, IgD and IgE. In normal serum, about 80% is IgG, 15% is IgA, 5% is IgM, 0.2% is IgD and a trace is IgE.¹

Quantitative serum immunoglobulin tests are used to detect abnormal levels of the three major classes (IgG, IgA and IgM). Testing is used to help diagnose various conditions and diseases that affect the levels of one or more of these immunoglobulin classes. Some conditions cause excess levels, some cause deficiencies, and others cause a combination of increased and decreased levels. IgD and IgE will not be discussed in this article.

An Indian man, aged in his 30s, presented with upper right-sided neck pain of 2 months duration. He denied fever, night sweats, malaise or weight loss. There was tenderness on the right side of C1, some reduced range of movement and mild neck stiffness. The patient was a professional who had worked for a decade in Kenya and had moved from India to Australia 3 years previously.

An otherwise healthy male, 17 years of age, presented with a 2 year history of an enlarging lump under the right great toenail. There was no history of trauma.

Examination revealed an exophytic, non-tender, fixed, firm flesh-coloured subungal nodule on the dorsal aspect of the right great toe. The lesion was about 10 mm in diameter and was associated with nail plate deformity and onycholysis (Figure 1). 

It is not uncommon for patients to own and use a home blood pressure monitoring (HBPM) machine as a means of self care of their blood pressure monitoring,^1–8 the assumption being that these machines are used appropriately and accurately.⁹ In reality, many patients are using HBPM machines haphazardly and have not received any formal advice or guidance about their use from their doctor.^2,3 A study conducted in Ontario, Canada, showed that although 63% of primary care physicians encouraged their hypertensive patients to monitor their own BP at home, only 8% were given specific training on proper measurement techniques.² Another Canadian study demonstrated that instruction from a healthcare professional was the strongest factor associated with regular HBPM machine use.³ A Hong Kong study found that 85% of patients using automated BP devices had no training on how to operate their machines and just over half had read the manufacturer’s user manual.⁸

A woman, 34 years of age, presented to an in-house company doctor for a pre-employment medical examination before accepting a position as an administrative executive. She was thin, appeared comfortable and alert, but had a ‘staring’ look. Her pulse was 125 bpm, regular in rhythm; blood pressure 110/80 mm Hg. She had detectable proptosis with eyelid retraction but lid lag was not elicited. Her thyroid was not palpable. She denied weight loss but was troubled by palpitations and anxiety, which she ascribed to work stress, and had led to her resignation from two previous positions for a ‘change of environment’.

The company required only standard blood tests and a chest radiograph as part of the examination. Suspecting hyperthyroidism, the examining physician, after obtaining informed consent, added thyroid function tests and an electrocardiogram.

Hyperthyroidism was confirmed by:

• elevated levels of free T4–51.0 pmol/L (normal range 9.0–25.0 pmol/L)
• free T3–15.8 pmol/L (normal range 3.5–6.5 pmol/L)
• low thyroid stimulating hormome levels of 0.01 mIU/L (normal range 0.4–4.7 mIU/L).

An electrocardiogram showed sinus tachycardia.

Treatment for thyrotoxicosis was initiated immediately and she was certified fit for her new position. With her consent, the doctor informed the company that she had an incidental non-life threatening medical condition that would require regular monitoring and treatment until stabilised, the details of which were not divulged as she had not consented to the provision of this information to her employer. She accepted the position and reported for work on the due date, 6 weeks later.

The doctor’s decision was questioned by the employer 6 months later because, even though under the company’s medical policy employees received medical benefits regardless of whether they were work related or not (with the usual exclusions, eg. dental procedures and cosmetic surgery), the company had incurred recurring medical expenses throughout her term of employment. The company was also wary about the possibility of increased sickness absence in the future.

DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.

• Current reaction: a patient develops new symptoms while taking a particular drug. Is the drug the cause of the symptoms and if so, should it be stopped?
• Previous reaction: in the recent or distant past; often the patient’s recall is poor and information is lacking. Can the drug be used again?

Deborah, 54 years of age, presents with concerns about the possibility of high cholesterol. She has no significant past history and is taking no prescribed or over-the-counter medications. Her brother, aged 58 years, has displipidaemia and symptomatic coronary heart disease, but there is no other family history of cardiac disease. Deborah is clinically well, with no symptoms of cardiorespiratory disease. She drinks 1–2 glasses of wine 2 days per week, her body mass index (BMI) is 31 with a waist circumference of 96 cm. Clinical examination is otherwise unremarkable. Baseline blood tests are performed, with results shown below (normal ranges are shown in parenthesis):

On the basis of her abnormal liver function tests (LFTs), viral and autoimmune serology is performed, which is normal. An abdominal ultrasound shows mild hepatomegaly with fatty infiltrate but no evidence of cirrhosis or portal hypertension.

What is the cause of Deborah’s abnormal LFTs, and is statin therapy appropriate?

A healthy 17-year-old male presented with a 2-week history of an erythematous, slightly painful plaque on the right lower leg that was preceded by an injury to the area. He was otherwise asymptomatic and appeared well. Medical history was unremarkable.

Physical examination revealed an erythematous plaque with cribriform erosions on its surface and a crusty edge (Figure 1). Laboratory tests were normal, except for the erythrocyte sedimentation rate (ESR) which was slightly high (31 mm/hr; normal range for men: 0–22 mm/hr). A skin biopsy was performed and showed a perivascular and perifollicular mixed infiltrate of neutrophils and lymphocytes from the epidermis to the subcutis. No bacterial or fungal micro-organisms were identified on culture.

The patient was treated empirically with topical antifungal therapy and followed up the next day. By this time, the superficial erosions were more pronounced and crusts had appeared on the surface of the lesion (Figure 2). After 3 days, the lesion was completely necrotic with a deeply ulcerated centre (Figure 3).

Max, a school teacher aged 52 years, presented with 5 days of left midfoot swelling. It was initially painless, but over the past 2 days had become painful after walking. He reported no fevers or other joint swelling and had no recollection of recent trauma. He had been diagnosed 17 years previously with type 2 diabetes mellitus, which was now complicated by nephropathy and retinopathy.

On examination, the left foot showed swelling at the medial midfoot, which was warm and inflamed with bounding dorsalis pedis and posterior tibialis pulses. No ulceration or open wounds were identified. There was no deformity noted on the right foot. Bilaterally, the feet had a loss of protective sensation with reduced pinprick sensation, absent monofilament test using 10 g Semmes Weinstein monofilament, as well as loss of vibration and proprioception.

Blood tests showed no significant changes of acute infection. Max’s white blood cell count was 10.1 g/dL, haemoglobin 11.9 g/dL, C-reactive protein 0.6 and HbA1c 8.1%. His serum uric acid level was normal. An X-ray of the left foot showed no evidence of fracture or bone destruction.

Based on the clinical assessment and lack of investigation findings, a provisional diagnosis of acute Charcot neuro-osteoarthropathy (CNO) of the left foot was made. Management was immediate offloading of the left foot with total contact casting in consultation with a specialist foot team. (Total contact casting is a fibreglass shell that fits around the leg and foot with a bar on the bottom to keep weight off the foot.) Max was advised to rest, but allowed partial weightbearing ambulation on the left foot by using a walking frame. At review 2 weeks later, he reported 5 days of right midfoot swelling. Clinically, there was swelling at the medial side of the right midfoot, which was similar to the left foot. All blood parameters were normal, effectively excluding cellulitis and acute gouty arthritis. An X-ray of the right foot showed no significant bone changes.

Similar to his first presentation, a provisional diagnosis of acute CNO of the right foot was made. Bilateral total contact casting was immediately instituted with wheelchair mobility. Both casts were removed biweekly to accommodate reduction of oedema and to monitor foot and skin changes. Signs of inflammation were monitored (eg. skin erythema, oedema, local skin warmness). Contact casting was completely removed after 8 weeks, when there were no signs of inflammation of either foot. Max was then reviewed biweekly to ensure no recurrence of CNO after the offloading period. A pair of extra-depth custom-made shoes with bilateral total contact insoles was prescribed for better plantar pressure distribution.

Max returned to work after 3 months. At 1 year follow up he did not have any further episodes of foot swelling or ulceration.

The Australian Red Cross Blood Service has experienced a growing number of referrals from general practitioners for therapeutic venesection for patients with elevated serum ferritin (SF) who do not meet the eligibility criteria of two HFE mutations or documented iron overload. Thirty-six percent of referrals to the Australian Red Cross Blood Service Therapeutic Venesection program in an 8 month period in 2011 were for patients with elevated SF and an HFE genotype not associated with iron overload.¹ Venesection therapy, while the mainstay of treatment for iron overload due to hereditary haemochromatosis (HH), does not address the underlying reasons for elevated SF in patients without true iron overload.²

A man, 18 years of age, presented with a 6-month history of a widespread itchy rash, more intense at night, which had appeared 1 month after returning from a holiday to the Dominican Republic. The rash initially appeared as white patches affecting the fingers. The patient reported unprotected heterosexual intercourse while on holiday. There was no previous or family history of atopic dermatitis, however, the patient’s sister had recently begun to experience similar symptoms.

Clinical examination revealed scattered excoriated papules over the trunk (Figure 1), limbs and hands (Figure 2). Intensely itchy nodules were observed on the scrotum (Figure 3). A prolonged course of oral antihistamine in addition to topical corticosteroids did not improve the symptoms. 

Jane, 67 years of age, lives in Sydney. You have known her for years and she is a lifelong nonsmoker. Over the past 4 years, each time you see her to review her hypertension, she is coughing delicately into her handkerchief and finding it difficult to talk in full sentences after walking from the waiting room to your office.

A woman, 55 years of age, with moderate chronic obstructive pulmonary disease (FEV₁ 59% predicted, SpO₂ 95% on room air) and mildly reduced exercise tolerance is planning a vacation to Machu Picchu, which is 2430 m above sea level. She has had one previous exacerbation of her COPD and asks, ‘Is it okay for me to travel with my lung disease?’

There are a number of general factors that should be taken into account when patients with chronic lung disease plan to travel. As with any chronic illness, it is important to ascertain how easy access will be to medical care; what standard that care is likely to be and the availability of medications at the planned destination.

A man, 23 years of age and previously well, presents with 2 months of cough, shortness of breath and weight loss. He reports intermittent fevers and flu-like symptoms over the same period. During a recent 2 week holiday to Bali he felt significantly better, but after returning home he has had a recurrence of symptoms.

Occupational and exposure history identifies him as commencing work at a mushroom farm 12 months ago where he is exposed to dust from the mixing of mushroom compost. He is not required to use respiratory protection at work. His cough and chest tightness usually start in the afternoon at work and persist into the evening. Other workers at the mushroom farm have reported similar symptoms and have had to leave the workplace as a result.

Identification of occupational and environmental causes of respiratory disease is important because control of these exposures may lead to a cure for some people and prevention of disease in others. In Australia and other developed countries, effective occupational health and safety legislation has resulted in protection of workers from traditional causes of occupational lung disease, such as asbestos and silica. Current exposures may be subtle and require a high index of suspicion from the treating clinician.

A previously well male, 18 years of age, from a rural community, presented with three painful, itchy nodules on the fingers of his left hand, which had been present for 1 week. He had been prescribed amoxicillin clavulanate but presented again when there was no improvement after 4 days of taking antibiotics.

Examination revealed three erythematous and umbilicated nodules without any halo, but with a central depression with exudate (Figure 1a). No specific treatment was instituted at this visit.

One week later the patient re-presented with new erythematous lesions on the palms and dorsum of his hands. The original three lesions had improved and were drier than previously (Figure 1b, c). The new lesions disappeared after 2 weeks and the original lesions after 4 weeks, without any other treatment.

An otherwise healthy male patient, 45 years of age, presented to a general practice clinic in regional Western Australia 1 week after developing a pruritic, spreading rash that started after returning from a holiday in Thailand with his family. He denied infective symptoms such as fever, rigors or chills. He had not been bitten by either mosquitoes or marine life during his stay.

Examination revealed rash in several distinct areas over the left flank (Figure 1). The rash was erythematous and serpiginous (Figure 2). Some excoriations were present. He was afebrile and did not have any palpable lymphadenopathy.

The general practitioner was in doubt as to the diagnosis and sought assistance through Tele-Derm National, a service provided by the Australian College of Rural and Remote Medicine (ACCRM). The GP submitted brief case notes and several photographs of the rash via the online portal.

Within the hour, a diagnostic and management plan was prepared by a dermatologist and an SMS notification of the findings sent to the referring GP.

Diarrhoea remains the largest infectious risk posed to the traveller while abroad or on their return home. A large percentage is due to bacterial infections such as enterotoxigenic Escherichia coli and resolve within days of onset. A small percentage of the travelling population will have prolonged symptoms that may disrupt either a long term holiday or a return to normal activities when they are at home.

Single completion items

DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.

An infant, aged 48 days, is brought in by her mother to her doctor because of a rash that started during the neonatal period. The rash appeared first on the side of the face, then rapidly spread over the whole body, including the limbs and scalp. During late pregnancy the mother also had a pruritic rash, as did the brother, who is 5 years of age and attends daycare.

On examination, the infant appeared irritable. The rash was polymorphous in appearance: maculopapular, vesicular and pustular. The rash covered the whole body, including the nailbeds (Figure 1).

The population of Australia is ageing: the median age of the population (a common measure of demography) has been increasing in a continuous fashion over the past several decades.¹ Adults aged >20 years and seniors aged >65 years have increased in both absolute numbers and as a percentage of the overall population. The ageing of the population has resulted in significant national attention focused on ensuring that adequate healthcare resources are made available to the adult segments of society. Specifically, much concern has been expressed regarding an adequate supply of primary healthcare providers for this population.^2–4

Some communities in remote areas of Australia differ demographically, culturally and in their heath needs from communities in the rest of the country. One example is the Cape York Peninsula region. In the 2006 census, 11 699 people were recorded as living in the region, with a population that is much younger than the rest of Australia. Within the general population, people over 50 years of age now outnumber people under 20 years of age. However, within Cape York, people aged under 20 years make up over 33% of the population and only 20% of people are over 50 years of age. Most of the population under 20 years of age are Aboriginal or Torres Strait Islander, with the majority living in one of eight remote Indigenous communities.¹

The Onkaparinga Clinical Education

Program (OCEP) is a new approach to

community based medical education

(CBME). It provides medical students

with longitudinal clinical experiences

grounded in urban general practice and

incorporates other community services

such as aged care, private specialists

and community hospital emergency

departments. Students see patients

with undifferentiated healthcare needs

and gain clinical experience across the

breadth of the curriculum.

Henry, 60 years of age, was referred by his general practitioner with a 3 month history of blurred vision in the left eye on a background of decreasing vision in both eyes over the preceding 6 months. He had not had his eyes examined for many years. His past medical history included hypertension, hypercholesterolaemia, type 2 diabetes mellitus, chronic renal impairment and peripheral vascular disease. Henry admitted to noncompliance with his medications and medical appointments.

On examination, visual acuity was 6/18 on the right and 6/12 on the left. There was no improvement with a pinhole. His pupils were equal and reactive, and there was no relative afferent pupillary defect. A tonometer was used to measure the intraocular pressure (which was normal bilaterally), the pupils where then dilated. The anterior segment was examined and demonstrated early cataracts bilaterally. Fundus examination showed the features seen in Figure 1 (right eye) and Figure 2 (left eye).

A male university student, 24 years of age, presented to his general practitioner because of a facial rash. He had a past history of eczema but no other significant past medical history and no allergies. He was not taking any regular medications.

One week earlier, he had experienced a low grade fever and a sore throat associated with a flare-up of his eczema. At that time, he had seen another GP who prescribed mometasone furoate 0.1% (1 mg/g) ointment, one application daily, and oral cephalexin 500 mg, two tablets twice daily. The patient was compliant with this treatment but now reported that since the initial consultation, the rash had worsened (Figure 1).

Good communication between health providers and patients is the cornerstone of high quality, patient centred care.¹ A caring attitude to the patient’s psychosocial/emotional needs is an important aspect of the patient experience and one that receives the greatest emphasis in the literature.² Patient centred care is associated with higher rates of patient satisfaction,³ adherence to treatment⁴ and psychological and physical functioning.⁵

Genital Chlamydia trachomatis infection is the most common curable sexually transmissible infection in Australia and the most prevalent sexually transmissible bacterial infection in the Western world.¹ Notification rates are rising, due to a real increase in prevalence and incidence as well as improved surveillance.² Infection causes significant morbidity, particularly from the complications of pelvic inflammatory disease and tubal infertility.^3,4

The prison setting provides a unique opportunity to address the physical and mental health needs of a profoundly disadvantaged population group, yet little is done to maintain or build upon the successes of prison health services once prisoners return to the community.¹

Jennifer, a scientist and married mother of three, was 38 years of age when she first disclosed a history of sexual violence: ‘Disclosing the fact that I had been sexually violated, not by strangers, but by people closely linked to my family was so shameful it made me stay silent for over 30 years.’ Up until this time, no healthcare professional had asked Jennifer if she had ever experienced sexual violence. Over a period of many years she had presented with a range of symptoms including abdominal pains, headaches, menorrhagia and episodic depression, including postnatal depression after the birth of her first child. She was treated with antidepressants for 12 months, but stopped taking these as they made her feel nauseous and robotic. She was not offered any counselling at this time. Medical procedures that required intimate contact sometimes triggered unexpected and unwanted responses. For example, Jennifer remembered having had two painful Pap tests in her 20s that had resulted in flashbacks, so she had avoided having Pap tests since. She was terrified of injections and avoided going to the dentist. She also felt guilty about the effects of her symptoms on her husband and children. Just before disclosing her history of sexual violence she had watched a documentary about child abuse and realised that her ongoing physical and emotional problems were identical to those experienced by other victims. Jennifer attended a general practitioner who asked her when she had last had a Pap test. When Jennifer told the GP that it had been 10 years before, the GP asked if there was a particular reason for this. Jennifer then disclosed her history of sexual violence.

Talking about her experiences of sexual violence for the first time caused Jennifer to experience further anxiety and panic attacks in the ensuing days after disclosure. The GP arranged a longer appointment at which they discussed treatment options. The GP told Jennifer that she was suffering from a form of post-traumatic stress. Having kept the history of sexual violence hidden for so long led to Jennifer experiencing physical symptoms as well as emotional pain. She and her GP worked together to deal with the painful aftermath of disclosure, and scheduled regular appointments to facilitate Jennifer receiving optimal healthcare.

A man, 20 years of age, is transferred to the emergency department after a road traffic accident. He has a visible forearm deformity and there is evidence of compromise of the skin overlying an obvious fracture. His forearm X-ray is shown in Figure 1.

Mrs MS, 81 years of age, presented to the emergency department with a 2 day history of left eye redness, worsening pain and watering. She had a history of glaucoma surgery with intra-operative topical antimetabolite in her left eye 3 years earlier. Visual acuity was documented as 6/18 in each eye. She was diagnosed with viral conjunctivitis and discharged home without ophthalmic review. Mrs MS re-presented the following day with worsening pain and vision. On examination, her left visual acuity was hand movements only. There was a 1.9 mm hypopyon (pus in the anterior chamber) and severe conjunctival injection (Figure 1). There was infection of her glaucoma surgery bleb at the superior limbus (Figure 2). Vitreous fluid obtained for Gram stain showed Gram positive cocci and Gram negative bacilli. She was treated with immediate intravitreal injection of ceftazidime 2.25 mg/0.1 mL and vancomycin 1.0 mg/0.1 mL. A vitrectomy was performed due to the severity of infection. One month postinfection her vision had recovered to 6/36.

Melba, 75 years of age, presented to her general practitioner with extensive left arm oedema 2 days after visiting a travel clinic for vaccinations in anticipation of travel to South America. There was no fever, pain or heat associated with the oedema. At the travel clinic she received a combined diphtheria-tetanus-acellular pertussis and inactivated poliovirus vaccine (Boostrix®-IPV) in her left arm at the deltoid subcutaneously, and yellow fever (live) and hepatitis A and typhoid fever vaccines in her right deltoid (intramuscularly).

Melba had a past history of a left mastectomy, axillary lymph node dissection and chest wall radiotherapy for node negative breast cancer 26 years previously. Her radiotherapy regimen was Cobalt radiotherapy given at 44 Gy over 22 fractions. She underwent a latissimus dorsi breast reconstruction a few years later. Before having the travel vaccinations, Melba had no visible oedema and no signs or symptoms to indicate the presence of lymphoedema. She took pantoprazole for gastrooesophageal reflux disease. There was no other significant medical or medication history.

Melba was started on cephalexin, 500 mg four times per day, to cover any possible developing infection. Over the following week, her arm oedema worsened, despite the antibiotic treatment. Melba was advised to consult her breast cancer surgeon who referred her to a lymphoedema clinic.

Melba was seen at the lymphoedema clinic 20 days after the vaccinations. Examination revealed extensive, predominantly pitting, oedema of the left forearm and upper arm, with mild oedema seen on the dorsum of the left hand. A single frequency bioimpedance analysis device was used to assess the extent of the lymphoedema (Table 1).^1–4 Melba's L-Dex® score was significantly elevated at 41.7. In addition, her left forearm circumference was 2.5 cm greater than the same reference point on her right arm. Importantly, Melba was right-handed and therefore probably had use hypertrophy of the right arm, which would have reduced the potential difference.

Melba started treatment with a physiotherapist for the lymphoedema, which included daily manual lymphatic drainage, daily multilayer bandaging from the dorsum of the hand to the upper arm and prescription of a compression garment. Two weeks later, the L-Dex® score was reduced to 28.0 and a marked reduction in arm oedema was observed. Melba then embarked on her South American holiday and was reassessed on her return, 3 months after the initial presentation at the lymphoedema clinic. At this visit, her L-Dex® score was 20.6 and on circumferential measurement, there was less than 2 cm circumferential difference between both arms and no obvious oedema was seen. It is unclear whether this score had returned to her prevaccination baseline, as there was no baseline available for comparison. Melba was asymptomatic and was discharged from the clinic and advised to return for further treatment should her symptoms return. She remains asymptomatic 1 year after discharge, without the need for daily use of a compression arm sleeve.

A young girl, 8 years of age, presented with bilateral great toenail discoloration, thickening and pain since infancy (Figure 1). She had been previously treated with topical antifungals for 1 year with no improvement and had been treated for two episodes of ingrown nail.

A teenage girl, 16 years of age, was referred with a similar history of dyschromic, thickened and painful great toenails since birth (Figure 2). Previous treatments included topical and oral antifungals, which proved unsuccessful, and surgical nail removal, which was followed by regrowth of the nail plate with identical deformity and discoloration.

On examination, both patients had greenish discoloration, hyperkeratosis, transverse ridging and lateral deviation of the great toenail.

Samantha, 29 years of age, presented with 3 days of worsening left iliac fossa pain at 9 weeks gestation with dichorionic-diamniotic (DCDA) twins. There was no vaginal bleeding, nausea, vomiting or diarrhoea.

She had experienced intermittent vaginal bleeding throughout the pregnancy, and had undergone ultrasound examinations at 5 and 7 weeks to investigate this. These scans showed a viable DCDA twin pregnancy with a left corpus luteum.

Samantha had a past history of polycystic ovarian syndrome and laparoscopic gastric banding surgery 4 years previously. She was gravida four para three, and had a history of two previous twin pregnancies and one previous singleton pregnancy. She had no history of pelvic inflammatory disease or fertility treatments.

On examination, Samantha appeared well. Her blood pressure was 134/77 and heart rate was 88 bpm. Abdominal examination revealed left iliac fossa tenderness with rebound and cross tenderness. Her haemoglobin level was 130 g/L.

An urgent transvaginal ultrasound scan was ordered which showed intrauterine twins and a left tubal ectopic pregnancy with a yolk sac and fetal pole, 7 week size by crown-rump length.

Much has been written about the health and life expectancy gap between Indigenous and non-Indigenous Australians.^1,2 While these disparities are greatest in remote areas, 60% of this 'gap' can be attributed to the significant disease burden carried by Aboriginal and Torres Strait Islander people living in nonremote areas of Australia. These people account for 61% of cardiovascular disease, 62% of diabetes, 64% of cancers, 83% of mental disorders and 66% of chronic respiratory disorders in the Aboriginal and Torres Strait Islander population.^1,3 Over 50% of Aboriginal and Torres Strait Islander people live in capital cities or regional centres.4 Further research is needed into the health status of this population and to guide effective disease management, public health and health promotion strategies.^5,3

James, aged 3 months, was brought to his general practitioner due to concerns about recurrent vomiting after feeds, which were nonbilious with no suggestion of haematemesis. James was born at term via spontaneous unassisted vaginal birth without complications. Growth parameters at birth were all on the 50th percentile. Complementary feeds with cow’s milk based formula were commenced from approximately 2 weeks of age due to maternal concern about poor feeding. Postfeed vomiting commenced around 4 weeks of age, although intake remained good. James was otherwise well between feeds, although bowel actions were frequent with 6–8 bowel actions per day with mild perianal excoriation noticed regularly. Eczema, which required the application of a mild topical steroid, commenced around this time. At his 3 month health check, the maternal and child health nurse noted that James’ weight gain had slowed to the 10th percentile while his length and head circumference remained on the 25th percentile.

In view of the ongoing vomiting and slowed weight gain, James’ GP prescribed ranitidine for the presumptive diagnosis of gastro-oesophageal reflux disease (GORD). Despite good medication compliance, James’ weight continued to decrease to just above the third percentile, with length on the 10th percentile, by 6 months of age. He was referred to a paediatric gastroenterologist for further assessment due to failure to thrive.

Following paediatric gastroenterologist assessment, James was investigated with barium meal, which ruled out gastric outlet obstruction and malrotation. Oesophageal pH study was not requested. Gastroscopy was performed and the results were macroscopically unremarkable. Histological findings from endoscopic biopsies showed a mixture of neutrophils and mild eosinophilia in the lower oesophagus and duodenum. Oesophageal eosinophilia was less than 15 per high power field with no basal cell proliferation, ruling out eosinophilic oesophagitis. The other biopsies were unremarkable with normal small intestinal disaccharidases, ruling out lactose intolerance.

These findings were consistent with GORD. Due to the timing of symptom development, the possibility of cow’s milk protein allergy was considered. James’ cow’s milk based formula was changed to an extensive hydrolysed formula, which coincided with his mother’s wish to cease breastfeeding. Over the subsequent 2 weeks his vomiting gradually improved with steady weight gain and resolution of frequent bowel actions, with 1–2 pasty bowel actions per day. Re-challenge with cow’s milk formula at home resulted in symptom recurrence confirming the diagnosis of cow’s milk protein induced GORD. Cow’s milk protein elimination advice was implemented and by the age of 10 months James’ weight and length had returned to the 25th percentile. At 18 months of age James was re-challenged with cow’s milk, with no recurrence of symptoms. This demonstrated evidence of allergy resolution.

A man, 33 years of age, presented complaining of asymptomatic lumps on the tattooed skin of his right upper arm. The lumps appeared spontaneously 5 months after getting the tattoo. He had no significant past medical or surgical history. On examination, several 3–4 mm shiny, umbilicated papules were seen on the tattooed skin (Figure 1). Tests for human immunodeficiency virus (HIV), hepatitis B virus, hepatitis C virus and syphilis were negative and full blood examination was normal.

Infection control and antibiotic resistant organisms are a community health concern. Research has focused on acute and high dependency facilities,^1,2 but with care of chronically ill patients increasingly taking place in the community, these patients may be more susceptible to persistent bacterial colonisation and invasive infection. Staphylococcus aureus (SA), particularly community acquired methicillin resistant Staphylococcus aureus (MRSA) is increasingly virulent and invasive.²

Olive, a widow, 75 years of age, has been attending your practice for over a decade. Three years ago she was diagnosed with Alzheimer disease but has remained relatively independent since. She lives with her daughter, Julie, and drives a car. Olive is compliant with her anticholinesterase medication. However, Julie reports further deterioration in her mother’s memory with recent episodes of wandering. Upon questioning you establish that Olive has been getting lost while driving. Furthermore, she has recently had a minor car crash and two near misses. During your consultation with Olive, she becomes defensive, denies a history of accidents and states confidently that she is a safe driver. In your office, her Mini-Mental State Examination score is 20/30. The remainder of her examination is unremarkable.

Frank, 28 years of age, presents to a general practitioner he has not seen before, with a history of purulent urethral discharge for 1 week. The GP explains to Frank that most causes of urethral discharge are sexually transmitted and asks him about his recent sexual contacts. Frank is running late for work and has difficulty concentrating on his sexual history. He discloses that he has a regular female partner but says, ‘I know where I got this.’ He denies same-sex contacts.

On examination Frank has a purulent urethral discharge which the GP collects for microscopy and culture for gonorrhoea. She also sends a first void urine sample for nucleic acid amplification testing for chlamydia and gonorrhoea and treats him for urethritis with azithromycin and ceftriaxone. She also gives him a request form to have serology for human immunodeficiency virus (HIV), hepatitis B and syphilis. The GP asks Frank to abstain from sex for a week until he sees her again to discuss the results.

On his return, the GP advises Frank that his tests show both chlamydia and gonorrhoea. She explains that both of these infections have been treated but that sexual contacts will need treatment too. She explains that the first person who needs to be advised is his regular partner. ‘She needs to be checked for her own health but this is also important so that you don’t get the infections back.’ Frank agrees to tell her himself.

The GP enquires about Frank’s other partners over the past 6 months and Frank discloses that he had sex with a woman he met in a bar in Bangkok 2 weeks ago and that he has had two other brief relationships with female partners 3 and 4 months ago. The GP explains that the woman from the bar should be informed about her risk of chlamydia and gonorrhoea, whereas the two previous girlfriends should be advised about the risk of chlamydia. Frank is initially confused as to why the ex-girlfriends need tracing and treatment but the GP explains that, while his symptoms were probably a result of the recently acquired gonorrhoea infection, he may have had asymptomatic chlamydia infection for some time. She explains that his ex-girlfriends may unknowingly have chlamydia and be at risk of pelvic infection or infertility. Frank has a name and a contact method (mobile number or email address) for all three and accepts the offer of provider referral for the woman from Bangkok. The GP explains that she will pass the details to her local sexual health clinic to facilitate the process.

The GP shows Frank the ‘Let them know’ website, which demonstrates how to tell partners directly or how to SMS or email partners with or without disclosing a name. He seems interested in this option for his previous girlfriends.

Frank’s blood results are all negative, but the GP explains that he is still in a window period for testing. He should use condoms and have another blood test in about 3 months. He should also be re-tested for chlamydia in 3 months. She asks Frank if it would be okay for her to call him in 2 weeks and see how he has gone telling his partners, and also to put him on the system for recall in 3 months. He agrees to this. When she calls, Frank reports that his regular partner has been informed and treated and that his ex-partners have been anonymously contacted. The GP thanks him and reminds him to attend for repeat testing.

• improving access and reducing inequity
• better management of chronic conditions
• increasing the focus on prevention
• improving quality, safety, performance and accountability.

Spirometry has become an important tool for general practitioners to diagnose and monitor chronic respiratory conditions.¹ About 65% of Australian practices own a spirometer.² Colonisation of respiratory pathogens in laboratory spirometers has been reported³ but no such data are available for general practice.⁴ Procedures for spirometer cleaning have been shown to be below laboratory standards in some overseas general practices.⁵ Because spirometers may harbour pathogenic micro-organisms, there is the potential risk of cross-transmission of aerolised respiratory pathogens. These pathogens are especially relevant to patients with chronic airways conditions, such as chronic obstructive pulmonary disease (COPD) and asthma, as they may cause aggravation of respiratory symptoms and exacerbations.

Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www.gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.

Marilyn is an accountant, 30 years of age, married for 8 years to a construction worker. She presents with low energy and headaches that have affected her for over a year. They have worsened in the past month (since her husband was laid off), affecting her mostly at the end of the day. She has trouble sleeping and reports aches and pains all over. She has been to several other clinics in the past year but has found nothing to be helpful. She has had blood tests, been prescribed painkillers, been advised to get more exercise and change her diet. She desperately needs something to be done for her today as her husband is getting impatient with the lack of results. She is concerned he will become very angry with her when she returns home today. Marilyn’s doctor asks, ‘what happens when your partner becomes angry?’ She has not previously been asked this question and she hesitates. Her doctor says, ‘I would really like to hear what is going on at home’. She bursts into tears and slowly the story of her experience of partner violence unfolds. The doctor assesses her safety and Marilyn indicates she feels she can manage what is happening for now. They make a follow up appointment for ongoing support.

Walter, 60 years of age, presented with a 2 year history of worsening snoring, poor sleep quality and daytime somnolence. He was a nonsmoker. His wife revealed she had recently noticed a hyponasal quality to his voice. His body mass index (BMI) was 26. Walter was referred to a sleep clinic where oral cavity examination showed a right sided oropharyngeal mass (Figure 1). This was biopsied and confirmed to be a pleomorphic adenoma of the parotid gland. Overnight polysomnography showed an oxygen desaturation index of >31 (severe obstructive sleep apnoea [OSA]). Walter underwent surgical resection and both his snoring and sleep apnoea resolved.

Case study 2

Paul, 39 years of age, presented with a 2 year history of progressively worsening snoring. He was otherwise healthy, did not smoke and had no other complaints. His BMI was normal. Paul was referred to a sleep clinic where he was noted to have a large right sided oropharyngeal mass (Figure 2). Biopsy confirmed his mass to be a sarcoma. Overnight polysomnography showed an oxygen desaturation index of >31 (severe OSA). He underwent surgery and postoperative chemoradiotherapy and both his snoring and OSA resolved.

Betty, 78 years of age, presented to the emergency department with an acutely painful discharging left eye on the background of a complex ocular history. While living overseas she had developed left eye herpes keratitis for which she sought treatment from an ophthalmologist. She had initially been prescribed oral valacyclovir tablets and then ongoing topical corticosteroid eye drops (dexamethasone 0.1%) and acyclovir eye ointment four times daily.

On arrival in Australia, Betty consulted a general practitioner for continuation of her treatment. The GP provided her with ongoing prescriptions for dexamethasone eye drops but inadvertently omitted the acyclovir eye ointment. No ophthalmology follow up was organised. Betty continued the dexamethasone drops unmonitored for several months.

On examination in the emergency department, Betty had no perception of light in her left eye. She had significant periorbital oedema and conjunctival chemosis. There was a large corneal abscess involving almost the entire corneal surface (Figure 1). There was an area of corneal thinning nasally, with evidence of corneal perforation. The anterior chamber was flat and the iris plugged the corneal perforation. She was febrile at 38ºC. Betty was admitted to hospital for treatment of a perforated corneal abscess. She was treated with intravenous antibiotics (ceftriaxone 1 g/day) and hourly fortified antibiotic eye drops (cephalothin 5% and gentamicin 0.9%). Despite several days of treatment, the eye was nonsalvageable and required evisceration (removal of the cornea and intraocular contents). The wound was left open to allow drainage of residual infection.

She underwent fitting of an ocular prosthesis 5 months later.

On 1 August 2007, a 17 month old child was seen by a paediatrician at St Ann's Hospital, London. The presenting problems were listed as aggressive behaviour, including biting and hitting other people, easy bruising and a fungal scalp infection. The paediatrician noted three bruises on the left side of the child's face and 10–15 bruises on his back. The paediatrician provided a referral for investigation of possible metabolic disease and discharged the patient home with his mother.

Two days later the patient was dead. A postmortem examination revealed multiple injuries, including eight fractured ribs, an area of bleeding around the spine at the cervical level and numerous bruises, cuts and abrasions.

In November 2008, the child's mother, her boyfriend, and his brother were convicted of causing or allowing the child's death.

An expert review of the case concluded that the bruising the patient presented with on 1 August 2007 was typical of child abuse, and should have been recognised as such by the paediatrician.

The information in this article has been compiled with input from Austroads and the National Transport Commission.

Two-thirds of the men at encounters for BPH were aged 65 years or older, so it was no surprise that patients were more likely than average to carry Commonwealth healthcare cards and Veterans' Affairs cards, and less likely to be new patients to the practice. More than 1% of encounters with male patients aged 65 years and over included management of BPH. There were no BPH encounters with men aged less than 45 years.

Compared with all problems managed at BEACH encounters, BPH was managed with low rates of medications prescribed, supplied or advised, and low rates of other treatments. Referrals to specialists were provided at three times the average rate, and pathology and imaging tests were ordered at twice the usual rate (Figure 1).

Joan, 64 years of age, has a past medical history of hypertension, rheumatic fever, appendicectomy and cholecystectomy. She presented to her general practitioner with difficulty in swallowing. Joan was otherwise well with no constitutional symptoms and no recent weight loss. She was suspected to have a foreign body lodged in her oesophagus.

Joan underwent an ultrasound which excluded a foreign body but detected an incidental finding of a right superior pole renal mass. A four phase computerised tomography scan was performed in order to further characterise the lesion. This showed a 25 mm enhancing lesion in the supero-posterior aspect of the right kidney (Figure 1). The contralateral kidney appeared normal. There was no renal vein tumour, thrombus or lymphadenopathy evident. Laboratory testing revealed renal impairment with a serum creatinine of 160 μmol/dL and an estimated glomerular filtration rate (eGFR) of 41.

A man, 44 years of age, presented with a 4 hour history of dizziness, blurred vision, dry mouth and dilated pupils. He was previously well and on no medications and there was no history of recent drug use, head injury or focal neurological symptoms. On questioning, the patient said that he had eaten lupini beans for lunch but that he hadn't had enough time to soak them for long enough before eating them.

On examination his Glasgow Coma Score (GCS) was 15/15, heart rate 98 bpm, blood pressure 144/98, temperature 37.8°C and respiratory rate 18 breaths/minute. His skin was warm and dry with dry mucous membranes. His pupils were dilated at 6 mm and were nonreactive. Cardiovascular, respiratory, abdominal and neurological examinations were normal. He was unable to pass urine. Electrocardiogram showed normal sinus rhythm with a rate of 98 bpm.

Michael, 32 years of age, presents to the hospital emergency department with chest pain of 4 hours duration.

A woman, 44 years of age, presented to a hand clinic in 2010 with a partial high median nerve lesion, 7 days after attempted removal of an impalpable etonogestrel implant. During the initial removal procedure she experienced a sudden shooting pain down her arm, followed by paraesthesia and dysaesthesia in her hand. The procedure was discontinued, and she attended a hospital emergency department.

Ultrasound showed the implant to be separate from the incision and in the subcutaneous plane. Its location was marked and she was referred to a hand clinic. At that stage, she had weakness of the muscles innervated by the median nerve and significant dysaesthesia and paraesthesia throughout its sensory distribution. The wound was explored under general anaesthesia 7 days from the original procedure, and a 10% laceration of the median nerve was repaired under the operating microscope. The implant was removed through a separate incision. Four months after the injury she had persistent weakness of her thenar muscles, however, her major disability was persistent dysaethesia and paraesthesia in her hand, which required treatment by a pain specialist.

A man, 35 years of age, with an unremarkable past medical history, attended after developing purplish nodules on the left arm. The nodules were in a linear distribution and had developed during recent months after a minor initial injury. The nodules were moderately painful, but it was mainly the appearance of new nodules that motivated him to consult his general practitioner.

On dermatological examination, six purple nodules were observed following a linear distribution along the back of the left hand and arm (Figure 1). They were of variable size. Some of the lesions had a discrete superficial ulceration and a serous crust.

The patient had no fever. Small lymph nodes were detected in the left axilla. Systemic examination showed no abnormalities. Laboratory data, including full blood count, general biochemistry and urine analysis were normal. Culture was unremarkable. Histopathologic examination revealed a mixed granulomatous and pyogenic inflammatory process. Cigar shaped organisms were identified by periodic acid-Schiff (PAS) staining.

Nathan, 3 years of age, presents with aggressive behaviour toward his younger sister, aged 2 years. When the sister is playing with a toy he wants, he hits her, sometimes causing injury. When he does this, the family sometimes put him in 'time out' and he emerges from this in a crying and distressed state. Mealtimes are very difficult as Nathan often refuses to sit at the table and eat. Mealtimes last 30 minutes and the television is on in the background. At bedtime Nathan has tantrums and refuses to stay in his bedroom. He runs in and out of his bedroom, trying to get his parents' attention. It can take 2 hours for him to eventually fall asleep. During the day he is tired and grumpy.

Nathan's developmental milestones are within normal limits and his mother says that when he is behaving well, she enjoys him. There is a history of parental depression and recent job loss for the father.

In your office, he plays quietly at first and then begins to throw toys. His examination, including height and weight, is normal.

Management of Nathan would include establishing the parents' goals for his behaviour and using reward charts to reward positive behaviour (eg. sitting at the table for mealtimes). 'Time out' should be reserved for serious behaviour and he should stay in 'time out' until he is calm. Meal times should be limited to 20 minutes with the television off, and the family should eat together. The parents should be supported in seeking mental healthcare.

Nerve conduction studies investigate how the nerves in your arms and legs are working. Nerves allow messages to pass as electrical impulses between your brain and the rest of your body. Sensory nerves are the ones that take messages from the skin, muscles and joints to the brain. They detect pain, movement and temperature. (Your senses, such as sight and taste, are very specialised sensory nerves). Motor nerves take messages from the brain and spinal cord to the muscles to get you moving. Nerve conduction studies can be used to test how both sensory and motor nerves are working in different parts of the body.

A man, 70 years of age, presented with a history of hyperpigmentation on his lower extremities. The rash was asymptomatic and the patient was uncertain how long it had been present. However, he recalled that it was definitely not present at his last appointment
10 months prior.

He had a past history of hypertension, hypercholesterolaemia, stroke and venous insufficiency. His usual medications were aspirin 81 mg/day and simvastatin 20 mg/day; he was also on hydrochlorothiazide/triamterene and gabapentin. In addition, a few months ago he was started on minocycline 100 mg/day orally by his urologist for prophylaxis of recurrent coagulase negative staphylococcal urinary tract infections in the setting of neurogenic bladder. The patient was quite pleased that he had experienced no recurrent urinary tract infections since starting minocycline.

Examination of his lower extremities revealed diffuse, macular dark bluish-black areas of discolouration. No crusting, ulceration, obvious haemosiderin deposition or oedema was present (Figure 1, 2).

Ambulatory electrocardiographic monitoring (AECG) involves electrically monitoring a person’s cardiac rhythm over a period of time while they go about their day-to-day activities. The different types of AECG are: Holter monitors, event recorders, and implantable loop recorders (ILRs).

A Holter monitor is a portable way of taking an electrical trace of your heartbeat over a period of time (usually 24 hours) while you go about your normal day-to-day activities. The machine records this trace so that a technician and cardiologist (heart doctor) can review your heart rhythm and report back information about your heart to your general practitioner. The test can help pick up if your heartbeat is too fast, too slow or irregular.

Mr Lin, a Chinese man aged 38 years, presented for review of a recent chest X-ray. The X-ray was ordered as part of a pre-employment assessment. He was asymptomatic, a nonsmoker and had no significant past medical history. Full blood examination, lipids, glucose and liver and renal function were normal (also ordered as part of the pre-employment assessment). On examination, he looked well, with blood pressure 134/78 mmHg, heart rate 72/min, and chest and cardiovascular examinations normal. His chest X-ray is shown in Figure 1.

A man, 26 years of age, presented to a hospital emergency department complaining of a sudden onset of a sore throat 6 hours previously while consuming a carbonated drink at work. The pain commenced about lunchtime, after he had been mixing concrete powder, and since then had been intermittent and was becoming more severe. He subsequently complained of upper chest pain that radiated down his left arm and into his jaw. He denied any nausea, vomiting or shortness of breath but had severe pain on swallowing. He had no relevant past medical history, was not taking
any medications and had no allergies.

Observations were unremarkable with temperature 36.6ºC, pulse 54 bpm and regular, pulse oximetry 99% on room air, and respirations 16 breaths/min with equal air entry on both sides. His oropharynx showed no tonsillar enlargement and only slight erythema. On palpation he had tenderness in the anterior part of his neck, but no tenderness in the supraclavicular region. There was no subcutaneous emphysema. A routine electrocardiogram showed normal sinus rhythm and no acute ischaemic changes and bloods were taken for a troponin level, which was normal. While recognising that the likely diagnosis was pharyngitis, the emergency nurse practitioner was concerned that his symptoms were more severe than expected for such minor clinical findings. For this reason, a soft tissue X-ray of his neck was taken (Figure 1).

A man, 47 years of age, with an unremarkable past medical history, attended our dermatology outpatient clinic having developed changes in the colour and texture of the hair of his left axillae 2 weeks earlier, causing him moderate itching. He did not remember any changes in his lifestyle or recall any changes in sweating patterns.

On dermatological examination, a green sheath covering terminal hairs was observed (Figure 1). Contralateral axilla was not involved. Examination with a Wood lamp showed a green fluorescence.

No lymphadenopathy was present and the remainder of the physical findings were within normal limits. Laboratory investigations, including full blood count, general biochemistry and urinalysis were normal.

Debbie, a single mother, 27 years of age, presented with 3 weeks of persistent vaginal discharge. The discharge was foul smelling, light green, of moderate volume without any blood stain or clot. She also experienced moderate suprapubic pain that was constant and without radiation. The pain was exacerbated by bearing down and was not relieved by nonsteroidal anti-inflammatory drugs. She did not experience fever, dysuria or loin pain. She had an intrauterine device inserted 4 years ago which gave her irregular, light menses with cycles ranging from 48–60 days; she could not recall the exact date of her last menstrual period and was overdue for a Pap test. She was unemployed and lived with her father, taking care of two young children. She maintained an active sex life without a steady partner, and had unprotected intercourse 1 month ago with an unknown, casual partner. She believed her vaginal discharge was caused by a sexually transmissible infection (STI) from that sexual encounter. Consequently, Debbie requested blood tests to exclude an STI, and in the hope of finding a 'quick fix' treatment.

When the receptionist in the practice raised concerns about the rudeness and agitation of some patients who were waiting to see their doctor, Dr Ofili decided to put a television into the waiting room. She had heard that a distraction could reduce the perceived waiting time for patients. She was surprised that the problems got worse, and wondered why.

Case study 2

When Dr Johnson built an extension to his clinic, he decided to build a meeting room in which he could fit all his staff. Over the following 6 months, he noticed that, apart from the monthly meeting for the whole team, it was used only occasionally and then only by a small group. He wondered whether he had made a sound decision by including it.

How often in general practice do you hear yourself offering this advice? Why do almost all drugs list rash as a side effect? How do they occur and what can you do to recognise and manage them?

Prostate specific antigen (PSA) is a glycoprotein produced solely by the prostate. Its function is to liquefy semen. Small amounts leak into the bloodstream, where it can be measured. Prostate specific antigen is tissue-specific but not cancer-specific. Elevated levels can occur in men with benign prostatic hypertrophy (BPH), prostatitis, urinary tract infection or prostatic infarction. Elevation also may occur after prostate biopsy, aggressive digital rectal examination (DRE), ejaculation, bicycle riding and physical exercise.

Prostate specific antigen (PSA) is a protein produced by the prostate. The PSA test can potentially be used for screening, monitoring, or diagnosis.

Marion, a university lecturer aged 48 years, presented to her general practitioner complaining of persistent hoarseness for 4–5 weeks. Over the preceding 5 months she had suffered two prolonged episodes of bacterial sinusitis and an infective exacerbation of her asthma, each requiring several weeks of various antibiotics and oral prednisone, and each associated with transient hoarseness. Marion has generally well controlled asthma and has used a medium dose inhaled corticosteroid (fluticasone/salmeterol via dry powder inhaler) for many years. She has also used an intranasal corticosteroid (budesonide 64 μg daily) on a daily basis for 2 years to help control symptoms of rhinosinusitis. She is a lifelong nonsmoker and is otherwise in good health. She rinses her mouth after each inhaled corticosteroid dose. She has no pets and does not live on a farm. The only travel she has done in the past few years is to the United Kingdom to attend a conference. During this trip she did
not travel to any rural areas.

Marion's GP was concerned about the persistent hoarseness and referred her to an ear, nose and throat (ENT) surgeon who examined her lower pharynx and larynx with a fibre optic scope. In his letter back to the GP he described seeing 'a small red nodule' on her left vocal cord at laryngoscopy. There were no other abnormal findings and she was advised to watch and wait.

After several weeks she returned to the ENT surgeon with worsening hoarseness. This time he performed microlaryngoscopy which demonstrated an inflamed, bulky left vocal cord covered with white debris. A biopsy was taken which was reported as growing both Aspergillus and Cryptococcus species. Marion was commenced on itraconazole 100 mg/day oral for 1 month. Despite several weeks of antifungal treatment, her symptoms did not improve. A microbiologist was consulted who suggested repeating the biopsy to reconfirm the pathogen. This second biopsy grew Candida species, and she was changed to fluconazole 200 mg/day oral for 2 weeks and referred to a speech therapist with gradual resolution of her hoarseness over the next 6 months. Marion had a chest X-ray (screening for lung cancer), which was unremarkable, and tests for human immunodeficiency virus (HIV) serology, full blood count and fasting blood glucose, which were all normal.

Marion's asthma had been well controlled for many years on a medium dose inhaled corticosteroid. She was referred to a respiratory physician for an opinion on ongoing management of her asthma and the decision was made to cease her inhaled and intranasal corticosteroids. She was temporarily changed to montelukast sodium 10 mg/day oral, however, this is not subsidised on the Pharmaceutical Benefits Scheme for adult asthma so she did not continue to use it. At the time of writing, she had ceased all her asthma medications and was doing surprisingly well.

Mrs AA, female, 27 years of age and of Middle Eastern descent, presented with a 1 year history of nonpruritic facial plaques. On examination, these plaques were 0.2–1.0 cm, scaly, atrophic, annular, hyperpigmented and located on her forehead, nose, chin and adjacent to her lips (Figure 1). She was otherwise well apart from iron deficiency anaemia treated with ferrous sulphate and recurrent headaches treated with paracetamol. She had completed a course of cephalexin 2 months before for a urinary tract infection. She had not taken any other medications in the preceding 12 months. Mrs AA had no family history of skin disorders.

Three weeks after his 18th birthday, Jordan consults Dr Grant about his acne. Dr Grant practices in a small country town and has known Jordan for 10 years. Dr Grant provides advice about acne and notices that Jordan seems less talkative than usual. There is a strong family history of depression, so Dr Grant asks Jordan about his general health.

Jordan admits that he is feeling self conscious about his appearance and has been feeling unhappy at times. He has read on the internet that acne and depression are often linked and has been wondering if he might have some symptoms of depression. Dr Grant checks that Jordan is not at risk of self harm, completes a physical examination and arranges blood tests. They agree that Jordan will return in a week and in the meantime will visit the BITEBACK, reachout and youthbeyondblue websites to learn more about depression.

When Jordan returns the following week, Dr Grant is able to rule out medical illness and clinical depression, but suggests that Jordan might benefit from learning some strategies to prevent depression. Jordan has read about cognitive behaviour therapy and would like to learn some coping strategies. He is not prepared to see the town’s only psychologist because she is his best friend’s mother, but he is interested in exploring online resources. Dr Grant knows that the local high school counsellor has used MoodGYM in her work with students and Jordan is happy to see her. Dr Grant arranges to see Jordan again in 2 weeks and invites him to make an earlier appointment if he wishes.

A urodynamic study checks how your bladder works by taking pressure readings using computerised equipment. ‘Fluoroscopic’ means that X-rays are taken at the same time to give an outline of your bladder and urethra (the tube that allows urine to pass from the bladder to the outside).

Medically unexplained symptoms are defined as ‘those symptoms having little or no basis in underlying organic disease (or) when organic disease exists, the symptoms are inconsistent with it or out of proportion to it’.²

The general practitioner received a telephone call from the police asking if she could write a death certificate for a patient who had attended the practice. The man, 83 years of age, had been found dead in bed by his wife that morning. One of the GP’s colleagues had looked after the patient for about 10 years, but the colleague was currently overseas and not contactable.

On review of the medical records, the GP noted that the patient had a history of ischaemic heart disease, having suffered a myocardial infarct 8 years earlier. The patient had undergone coronary artery stenting 3 years ago. According to the medical records, the GP’s colleague had last seen the patient about 2 months before his death. At this time, the patient was well and he had attended for repeat prescriptions of his cardiac medications.

According to the police officer, the patient’s wife reported that her husband had been well since his visit to the GP and he had not seen any other doctors or attended hospital since this time. On the night before his death, the patient said he felt unwell and had some chest pain for which he had taken Anginine.

The GP was not sure if she could write a death certificate for the patient in this situation and contacted her medical defence organisation for advice. The medicolegal adviser informed the GP that if she was ‘comfortably satisfied’ as to the cause of the patient’s death, then on the basis that she was responsible for the management of her colleague’s patients in his absence, she was authorised to provide a death certificate. If the GP wanted to discuss the situation further, she could also obtain telephone advice from the Coroner’s office about whether she should write the death certificate.

Mrs FW, 83 years of age, presented to the emergency department with repeated episodes of attacks of vomiting over several months, coughing, weight loss and worsening shortness of breath. On examination she was not distressed, but mildly dehydrated. Chest examination revealed decreased air entry in both sides of the chest. Heart sounds were muffled. Other examination was within normal limits.

Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www.gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.

• healthy lifestyle
• metformin, sulphonylurea if tolerated, and finally
• consideration of a glitazone or insulin.¹

The oral hypoglycaemic agents (OHAs) controlling postprandial glycaemia were not often used – meal time acarbose (Glucobay) slowing carbohydrate digestion or repaglinide (Novo Norm) transiently increasing prandial insulin secretion.

• Young people’s perceptions of mental health problems in themselves and their peers
• Young people’s experiences of help and the importance of trust
• Young people’s perceptions of e-help and concerns about trust.

Learning objectives

After completion of this activity participants will be able to:

• conduct a consultation aiming to change the health beliefs of a patient
• identify the required monitoring and impact on preventive activities of disease modifying anti-rheumatic medications (DMARDs)
• suggest ways to minimise the functional impact of arthritis on a patient
• describe your approach to complementary medicines
• examine and identify improvements in practice systems to identify patients taking DMARDs.

Single completion items

DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.

Learning objectives

After completion of this activity participants will be able to:

• apply advanced communication skills to a problem in a consultation
• discuss critically a range of options to manage a drug misuse problem
• recognise and cite evidence for and against a view of whether a problem exists
• suggest challenges and possible solutions to professional role challenges
• describe the local addiction medicine services and how to access appropriate services for your patients.

Single completion items

Learning objectives

After completion of this activity participants will be able to:

• identify areas of communication in discussing challenging content that could be improved
• devise a method to incorporate the use of clinical decision tools into clinical practice
• analyse the feasibility of a suggested approach to your individual clinical practice
• integrate knowledge from either decision aids or the individual patient into decision making when there is uncertainty
• discuss critically the systems in your practice for warfarin management.

• a midline primary pit (or more than one) at the base of the natal cleft, which is epithelial lined and usually not inflamed and may have a hair (or several hair fragments) inserted into it that can be pulled out
• a secondary opening which, if present, is usually on one side and cranial to the primary pit. It may be a scar of a previous opening. If open, it may discharge pus or blood and be lined by granulation tissue. There may be a palpable track leading from the midline pit. More than one secondary opening means the sinus track has branches.

Learning objectives

• apply a range of communication strategies when discussing potentially sensitive areas
• describe the equipment required for a specific office procedure or the aftercare of a patient who has had a specific surgical procedure
• identify deficiencies and potential improvement in the identification and management of patients who have had a splenectomy
• use a range of relevant patient information sources
• discuss the role of the compounding pharmacist.

Single completion items

DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.

• Is the patient at risk of DKA?
• Are there clinical symptoms suggestive of DKA?
• What are the initial investigations needed?
• What is the initial therapy?
• Who needs to be contacted?
• What does the specialist treatment include?
• How will the patient be followed up?

Two typical scenarios are described in Case study 1 and 2.