Clinical Cases for General Practice Exams - sample Chapter

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This second edition maintains the role-play style of the successful first edition, where students use a variety of case studies to practise their clinical examination skills. Each case has been revised, and 25 new cases have been added. All cases include instructions for both the exam candidate and the patient, with suggested approaches as well as up-to-date references and further readings. The format is ideal for students, international medical graduates and general practice training programs.

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Clinical Cases for General Practice Exams - sample Chapter

  1. 1. 1 Section 1 Adolescent health Case 1 Erin Campbell Instructions for the doctor This is a short case. Please take a history from Erin, examine her face only, then outline the most likely diagnosis and negotiate a management plan with her. Scenario Erin Campbell is a 14-year-old girl who presents to you with moderate facial acne. Her mum has come with her to the surgery but lets Erin see you on her own. The following information is on her summary sheet: Past medical history Nil significant Medication Nil Allergies Nil Immunisations Up to date Social history Lives with parents.
  2. 2. SECTION 1 ADOLESCENT HEALTH 2 Instructions for the patient Erin Campbell You are 14 years old and attend the local high school. Your zits dominate your life. Each morning your mum shouts at you to get dressed and ready for school while you stare at your zits in the mirror. You are convinced that you will never have a boyfriend like all your other friends. You used to take comfort in eating chocolate and cheese but have stopped since a friend said that was causing your zits. You are embarrassed to be going to see the GP and hope the doctor will be kind. The following information is on your summary sheet: Past medical history Nil significant Medication Nil Allergies Nil Immunisations Up to date Social history Lives with Mum.
  3. 3. ERIN CAMPBELL CASE 1 3 Suggested approach to the case Establish rapport with Erin Open-ended questions to explore Erin’s concerns and expectations about her acne. Specific questions Duration of acne Location of acne Impact of acne on social life and relationships What has she tried so far as treatment? What does she think causes the acne? General health, e.g. are her periods regular? Request permission to examine. Examination Examine the face —confirm acne —describe signs: comedones, pustules, erythema or scarring. Management Explain medical understanding of cause of acne without using jargon Reassure that diet is not proven to change acne Reassure that acne can be controlled, should not stop her socialising Advise against picking or squeezing Offer treatment depending on what Erin has already tried Advise regular washing with soap Avoid oily or greasy skin preparations Treatment takes 4–8 weeks to be effective, can combine topical and oral treatments Reduce excess cells (hyperkeratinisation)1 Topical retinoids, azelaic acid
  4. 4. SECTION 1 ADOLESCENT HEALTH 4 Reduce bacteria (propioniobacterium acnes) Benzoyl peroxide, strength according to skin type Topical antibiotics (combine with Benzoyl peroxide to reduce antibiotic resistance)2 Oral antibiotics—tetracyclines not recommended until bone and teeth development complete Rebalance hormones (reduce androgen excess) Oral contraceptives containing an anti-androgen, such as cyproterone with ethinyloestradiol Reduce sebum hypersecretion Oral isotretinoin—high risk of teratogenicity Arrange follow-up. Case commentary Adolescent acne is a common problem and can lead to physical and psychological scarring.3 Refer to Figure 1, centre insert page A.4 Myths about its cause abound but the doctor can reassure Erin that the acne is not her fault and is not related to junk food. However, there are other good reasons to encourage a healthy diet. Typically many treatments will have been tried at home prior to consulting a GP. It is important to find out what Erin has tried so you are offering something new rather than a treatment that has already been tried and failed. For some teenagers, the hidden agenda of an acne presentation is a request for contraception. This requires sensitive exploration. A phrase that I find useful is: ‘Some people who come to see me know that the contraceptive pill helps with their skin; is this the case with you?’ The question about Erin’s periods is to assess the likelihood of polycystic ovarian syndrome. Common pitfalls Teenagers determine the severity and impact of their acne, not doctors. This case tests the doctor’s ability to practise in a patient-centred framework. Low marks will be given to doctors who dismiss Erin as having a few pimples which are insignificant and which she should learn to live with.
  5. 5. ERIN CAMPBELL CASE 1 5 References 1. Goodman, G 2006, ‘Managing acne vulgaris effectively’, Australian Family Physician, vol. 35, no. 9, pp. 705–8. 2. Laubscher, T, Regier, L & Jin, M et al. 2009, ‘Taking the stress out of acne management’, Canadian Family Physician, vol. 55, no. 3, pp. 266–9. 3. Goodman, G 2006, ‘Acne and acne scarring: the case for active and early intervention’, Australian Family Physician, vol. 35, no. 7, pp. 503–4. 4. Usatine, RP, Smith, MA & Mayeavz Jr, EJ 2009. The Color Atlas of Family Medicine, McGraw-Hill, New York, NY, p. 439.

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