Clinical challenge

Case 1: Mary

Mary, aged 25 years, is an Aboriginal and Torres Strait Islander woman living in a remote community. She presents to you for antenatal care. Mary has been pregnant three times, has had one live birth and has had one abortion (G3P1A1). She is approximately 10 weeks pregnant.

Question 1

Which of the following statement(s) regarding rates of adverse perinatal outcomes for Aboriginal and Torres Strait Islander mothers and babies compared to the non-Indigenous population is/are CORRECT?

1. Maternal mortality is increased.
2. Pre-term birth is increased.
3. Low birth weight is increased.
4. Perinatal deaths are increased.
5. All of the above.

Question 2

Which of the following lifestyle factors have been identified as contributing to adverse pregnancy outcomes in Aboriginal and Torres Strait Islander peoples?

1. Poor nutrition.
2. Higher psychosocial stressors.
3. Smoking.
4. Lack of physical activity.
5. All of the above.

Question 3

Improving the uptake of antenatal care is important in improving outcomes for Aboriginal and Torres Strait Islander women. Which of the following statements regarding antenatal care in this population is INCORRECT?

1. Cultural competence is essential for effective communication.
2. Assistance from Aboriginal health workers should be sought to facilitate understanding between the pregnant woman and her healthcare provider.
3. Specific programs to improve the delivery of antenatal services have not been shown to improve the uptake of antenatal care.
4. The experience of antenatal care may be improved by taking an individualised approach.
5. A number of tools and training programs have been developed to improve cultural competence.

Question 4

Mary is a smoker and has continued to smoke during her pregnancy. Which of the following statements regarding smoking in pregnant Aboriginal and Torres Strait Islander women is INCORRECT?

1. There are higher rates of smoking compared to the non-Indigenous population.
2. Nicotine replacement therapy has been demonstrated to be effective in this group.
3. Clinicians may be hesitant to ask pregnant women about smoking.
4. Women’s knowledge of the risks of smoking in pregnancy may be limited.
5. The benefits of quitting should be discussed and cessation advice provided.

Case 2: Frederick

Frederick, age 55 years, presents to you in the company of his family. They state that he has been more agitated recently following the death of his wife by suicide, and has been hearing voices of people that are not present. He has a past medical history of alcohol and cannabis abuse. He lives in a remote community and is of Aboriginal and Torres Strait Islander descent.

Question 5

With regards to psychotic disorders in the Aboriginal and Torres Strait Islander population, which of the following statements is INCORRECT?

1. Psychotic disorders are increasingly common in Aboriginal and Torres Strait Islander populations.
2. Psychotic disorders are often caused or exacerbated by substance use, particularly cannabis.
3. Paranormal experiences (visions and voices) and beliefs are unexpected accompaniments to grieving or traditional activities.
4. Sorcery is commonly invoked to explain unanticipated illness or death.
5. Differentiating paranormal experiences from psychosis can be difficult, and input from local Aboriginal and Torres Strait Islander informants may be helpful.

Question 6

Frederick has sustained self-inflicted lacerations to his arms. With regards to self-harm and suicide in Aboriginal and Torres Strait Islander populations, which of the following statements is INCORRECT?

1. Completed suicide is more common compared to the general population.
2. Self-harm is more common in Aboriginal and Torres Strait Islander populations.
3. Self-inflicted lacerations may be a traditional part of the grieving process.
4. Non-traditional self-mutilation is more likely to occur in younger and intoxicated individuals.
5. Completed suicide is more likely in older individuals.

Question 7

Frederick has previously presented with depression and anxiety. Which one of the following statements regarding depression and anxiety in the Aboriginal and Torres Strait Islander population is INCORRECT?

1. The Patient Health Questionnaire (PHQ-9) for depression has been evaluated in the Aboriginal and Torres Strait Islander context.
2. Depression and anxiety are often associated with somatic symptoms.
3. Depression and anxiety are often associated with comorbid illness.
4. Depression and anxiety are rare in this population.
5. Patients should be screened for depression.

Question 8

The family has noted a decline in Frederick’s memory over the past few years. With regards to cognitive decline in Aboriginal and Torres Strait Islander peoples, which one of the following statements is CORRECT?

1. Cognitive decline is more common compared to the non-Indigenous population.
2. The Kimberley Indigenous Cognitive Assessment (KICA-Cog) has been developed for use in urban settings.
3. The KICA-Cog is the most appropriate tool for cognitive assessment in all Indigenous patients.
4. The mini-mental state examination should not be used in the assessment of Aboriginal and Torres Strait Islander patients.
5. The elderly constitute a similar proportion of the Aboriginal and Torres Strait Islander population when compared to the general population.

Case 3: Justin

Justin, age 8, lives in a remote Aboriginal and Torres Strait Islander community. He presents to you with crusted and weeping skin lesions on the face and hands of several days duration, consistent with impetigo.

Question 9

Which of the following statements regarding bacterial skin infections is INCORRECT?

1. Topical antibiotics should be used with caution as they may be associated with the development of resistance.
2. Topical antibiotics can be applied once as part of a dressing.
3. Bacterial skin infections have a risk of significant complications.
4. Twice daily cephalexin is a useful alternative to flucloxacillin.
5. A child with multiple skin sores in numerous locations should receive oral or intramuscular antibiotics, not just topical treatment.

Question 10

Justin has four siblings living with him at home and attends school. Which of the following statement(s) regarding reducing the risk of spread is/are CORRECT?

1. Weeping or open impetigo should be covered with a waterproof dressing.
2. Certain guidelines recommend that the child remain at home until all weeping areas have dried up.
3. Careful personal hygiene and handwashing for patients and their relatives should be emphasised.
4. Home visits and follow-up by Aboriginal health workers can help ensure the infection has cleared.
5. All of the above.

Question 11

Which of the statements regarding community-based interventions for prevention of skin infections in Aboriginal and Torres Strait Islander communities is INCORRECT?

1. Overcrowding increases the risk of exposure and makes clearance of diseases more difficult.
2. Access to functioning washing machines can facilitate the availability of clean linen.
3. Community swimming pools have been linked to an increase in skin infections.
4. Use of showering for children instead of shared bath facilities can reduce the spread of infections.
5. Overall standards of housing and accommodation contribute to the spread of infections.

Question 12

Justin returns after 5 days of therapy with cephalexin. His condition has not improved. Which of the following statements regarding treatment failure is INCORRECT?

1. It may be associated with medication non-compliance.
2. It is essential to take swabs or scrapings as appropriate to confirm the diagnosis for persistent infections.
3. In far north Queensland approximately 50% of staphylococcal infections are attributed to community-acquired methicillin-resistant S aureus (MRSA).
4. In far north Queensland the majority of bacterial skin infections are due to a combination of streptococcal and staphylococcal organisms.
5. Consider perianal and nasal swabs to look for MRSA carriers if re-infection occurs.