Grad Caps

Question 1

Reflective practitioner

Recognises the influence of contextual, social, political and cultural factors on situations and takes these into account when acting and justifying actions.

Answer 1

• 15 year old boy with hepatic encephalopathy
• clearly a type of status that came with being a doctor that made it socially acceptable, if not normal, for the doctors to be so paternalistic
• I could imagine that after years of dealing with that level of suffering I too might become detached as a means of coping
• This lead me to reflect on the fact that his actions were not intrinsically right or wrong
• In Australia, we value patient autonomy and beneficence
• therefore, the same actions in this context would appear immoral
• But in Zambia, that is not necessarily so
• Over there, the ethics were much more utilitarian – trying to make the little resources that they have go as far as possible
• As a result, the individual was less important
• Clearly, it is the changing context, with its cultural and social factors bubbling through, that make our actions right or wrong, not the actions themselves

Question 2

Self-directed learning

Learning projects

Answer 2

• Negotiated capability for med, emergency and childrens health.
• Negotiated assignment for childrens health.

DEA

• Campus representative
• Organisation focuses on the health impacts of climate change
• My involvement isn’t due to environmentalist reasons
• There is no greater threat to health and I see it as part of a doctors responsibility to promote health
• Goal was to research and initiate efforts to make port base greener
• Side tracked by covid
• Focus became on learning as much about climate health as possible
• Wrote negotiated assignment on the ethical obligation that a doctor has to protect against the effects of climate change
• Hoping to publish it with the head of paediatrics, somewhere informally

Question 3

Using basic and clinical sciences

Anticipates possible complications and their patho physiological basis, as well as measures for prevention and treatment (i.e. work out other courses that the disease process could have taken, and other management options).

Answer 3

• Cirrhosis in zambia
• Obviously irreversible so management focuses on anticipating and preventing complications
• Many fatal complications of cirrhosis such as hepatocellular carcinoma
• In an effort to avoid costly investigations, there was an emphasis on empirical prophylaxis against complications that were fatal in the short term
• Without ready access to gastroscopy, every patient was placed on a beta blocker, assuming that they had varices
• Patients were diuresed as this has been shown to decrease the incidence of SBP
• Patients were given albumin to protect against hepatorenal syndrome

Question 4

Using basic and clinical sciences

Predicts likely outcomes of disease and prioritises approaches to individuals with multiple diseases or multi-system diseases, based upon principles of basic/medical science.

Answer 4

• 3 year old with urticarial rash, vomiting, syncope, febrile (Childrens health term)
• Multi system presentation involving skin, GI, cardiovascular
• When I heard this patients hand over on the ward round I was convinced that it was anaphylaxis as it fit the criteria used in America
• Clearly, determining if it was or was not anaphylaxis was not important for her current management
• She had presented the night before and was comfortably playing in the room by the time we did that ward round the next morning
• But I knew that if it was anaphylaxis, she would need follow up with an allergen-immunologist to confirm the diagnosis and determine the trigger
• she would also need education around allergen avoidance
• most importantly, she needed to be discharged with a script for two epi pens because of the risk of recurrence
• I raised my concern with the consultant who said that it couldn’t be anaphylaxis because there was no respiratory involvement
• I knew that this was not part of the criteria, so this made me worry more that they were missing a vital diagnosis
• Fortunately, when I reviewed the patients notes it was clear from the time course that it couldn’t be anaphylaxis. It was most likely a viral urticaria
• This encounter inspired me to research the validity of the criteria used for diagnosing anaphylaxis by different groups
• I developed an appreciate for the difficulty in diagnosing this undifferentiated multi system diseases without a gold standard investigation to refer to
• My concern was a typical example of how the criteria that are used to counter this lack of an objective marker are always more sensitive than they are specific, which inevitably leads to over diagnosing

Question 5

Using basic and clinical sciences

Plans and justifies a series of rational and appropriate investigations and / or screening test options, using EBM skills to take cost-effectiveness, benefit and test accuracy into consideration.

*

Answer 5

• Saw many cases of exacerbations of heart failure during my medicine term
• While preparing for biomed, I learnt the possible work up with everything from troponins to BNPs on the list
• It wasn’t until I listened to a podcast on heart failure this year that things were finally simplified
• The guest said that if they were on a desert island and could only order three tests it would be the Cr, K and Na
• These were not the investigations that came to mind when I thought of heart failure
• But her whole point was that there was no point in ordering something if it doesn’t change her management
• BNP levels rising or falling did not alter her management
• But knowing the Cr told her how aggressively she could diurese the patient
• The Na was an indicator of severity, fluid overload and decreased renal perfusion
• The K was a key baseline for the major complication of treatment, hypokalaemia
• This guided not only my approach to ordering investigations, but also the history
• It either needs to confirm the diagnosis or influence management (AF with CHADSVASC and HASBLED score)

Question 6

Teamwork

COVID clinic

Answer 6

• The students saw themselves as part of the hospital community
• Our goal was to lessen the burden on the over worked ED
• Triaging patients with algorithm to follow
• Deciding who needed to go to red ED, green ED, or get tested and go home
• The key issue was not becoming too tunnel visioned on covid. People were still coming to ED for all the other important reasons that they usually do.
• While we didn’t want people coming in and crowding the ED unnecessarily, our worst fear was sending someone home when they needed to be admitted

Question 7

Teamwork

Recognises the significant features of a team, including roles, responsibilities, personalities and power relations.

*

Answer 7

• Many key components of teamwork
• Leadership, backup behaviour, mutual performance monitoring, adaptability
• Supported by a shared mental model, trust, and communication
• I think communication is the most pivotal. No other aspect can function effectively without it
• This was highlighted to me by a video that I watched on emergencypaedia
• Recounts the death of a young lady after a routine operation
• Something had gone wrong and they were the dreaded position of cant intubate can ventilate
• There were three consultants in the room
• The author describes there being a loss of awareness. Specifically, awareness of what was happening was not shared by each of the consultants
• In other words, the team had lost their shared mental model, no one could lead and they couldn’t adapt to the new situation because no information was flowing between the team members
• In the inquest, the nurses stated that they knew exactly what needed to happen but didn’t know how to communicate it
• A nurse fetched a tracheostomy kit and announced it was available. There was no response
• There are many barriers to good communication in medicine
• The strong hierarchy undoubtedly played a role as well as a fear of being wrong, not trusting the other members of the team to receive the information in good faith
• A solution is graded assertiveness
• CUSS concern, unsure, safety, stop

Question 8

Teamwork

Analyses and solves problems collaboratively.·

Answer 8

· Neonatal intubation for persistent pulmonary hypertension

· during a time out before the procedure the neonatologist prescribed each person a role and outlined each step of the procedure

· he was ensuring that everyone had a shared goal and an understanding of their own role and everyone else’s in achieving it

· this allowed for mutual performance monitoring and backup behaviour

· during the intubation, the baby’s saturations began to fall steeply

· each member called out that there were no issues

· after a short while, the neonatologist realised that the oxygen was on at the wall but not the baby’s ventilator machine

· their saturations corrected quickly and they were transferred to a tertiary center in a stable condition

· at the mortality and morbidity meeting, I learnt that this was actually a relatively minor complication in the scheme of things

· by communicating effectively, the team had adapted flexibly to the new condition, the neonatologist was able to lead effectively, and a more serious outcome was avoided

Question 9

Teamwork

Understands events in a team from others’ viewpoints, including identifying their goals and recognising their feelings.·

Answer 9

· Small class during rotations in port Macquarie

· We only had three

· We had an ongoing issue where one of the students in the group was absent at a lot of classes

· Very noticeable when a third of the class is missing

· We kept finding ourselves in the position of having to apologise for this student or make excuses

· The other student became very frustrated and sent me a copy of the message that she planned to send him

· It was incredibly indirect and made it sound like she was just frustrated in general at people not attending classes

· I told her not to send the message

· I said that the other student probably had no idea that he was putting us in an awkward situation. He may be missing class for any number of personal reasons.

· We should give him the opportunity to change his behaviour and to do that he needs proper feedback, saying specifically what we are upset about and what we would like to change moving forward

· She sent a new message that did just that and sure enough he wrote back saying that he had no idea, that he was happy to take over some extra ward rounds from us to pick up the slack, and it was never an issue again moving forward

· This was an important lesson to me to not assume that you understand the viewpoint of another person in the team

· Communicate and pass information freely between members and then everyone can make informed decisions that are oriented towards the teams shared goal

Question 10

Teamwork

Behaves pro-actively, taking action and responsibility when necessary.

*

Answer 10

• Simulation of being in remote ED when child comes in with status epilepticus
• I was assigned airway doctor
• I secured the airway with a jaw thrust and chin lift
• There were no other airway or breathing issues
• I knew the status pathway and was aware that one of the final steps is with ongoing deterioration is making the decision to intubate
• This was not a skill that I was comfortable with, and so I became fixated and worried that I was going to need to do it
• Then the child stopped breathing spontaneously and I made the first steps towards intubating
• The teacher asked if maybe I should trial a less invasive intervention first like a bag mask valve
• Flustered, I first attached the adult sized mask and then attached the hose to air instead of oxygen at the wall, wasting crucial seconds
• In the debrief after I reflected that I had cognitively offloaded to the treatment algorithm and had become passive in my role
• When the airway was secure I should have been planning my next steps for if and when it deteriorated
• I have had several simulation sessions since, and have focused on taking any moment of respite in my role to actively plan and anticipate my next steps, as well as consider whether I need to assist a team mate in their tasks

Question 11

Effective communication

Communicates effectively across a clinical team including accurate and pertinent documentation.

*

Answer 11

• Received consistently good marks and feedback for communication with patients
• But provided summarys of patient presentations or brief handovers to colleagues has been a skill that I have always found challenging
• Emergency feedback to continue practicing and developing this skill
• There was a surgical tutorial that really changed my approach to this common scenario
• We were split into two groups to work up a patient and then hand it over to the other team as though we were finishing our shift
• My patient had presented with chronic limb ischaemia requiring revascularisation
• I made a passable handover using the ISBAR format
• I stated that the patient had chronic limb ischaemia, was previously on warfarin after a previous episode and had increased her dose prior to administration thinking that it would reduce the pain. Her INR was above 5 on admission
• The current goal of management was to bridge her back into a therapeutic range with her current INR being just above 1
• The consultant point out to me that I made several important omissions
• I needed to describe that the patient had gangrene on her fifth and first toe
• That I couldn’t feel any pulses but that the foot was warm
• This would prevent a colleague from wondering if the gangrene and lack of pulses was a new complication
• I should have also communicated that the reason she was on warfarin was because of a previous reaction to a DOAC
• This would prevent a colleague from adjusting her medications in light of her poor INR control
• This experience taught me that the key was to put myself in my colleagues shoes
• Try to determine what information they needed to in order to take on the care of the patient
• Shown significant improvement in this area
• Received P+ in final terms OnG and selective for effective communication
• Comment from OnG supervisor that I was a good communicator

Question 12

Effective communication

Communicates bad news sensitively.

Answer 12

• 81 year old man with hepatocellular carcinoma in zambia
• Without access to a CT scanner a raised AFP was often used to confirm the diagnosis of HCC in a patient with decompensated cirrhosis
• On this occasion there were 20 students crowded around the patients bed as the consultant received the investigation results
• He then spoke openly to the class about the diagnosis and questioned several students about its pathophysiology
• Finally he turned to the patients daughter and the first thing he said was “so this is palliative”
• Without discussing the diagnosis or prognosis, he immediately began to argue with her about how he could not remain in hospital as there was nothing they would do and he was using up a bed
• We have been taught many times that bad news should be broken in a quiet private place, there should be appropriate education given to the patient about management options and the likely progression and ample time for questions and concerns
• I always took these points for granted
• It was not until I saw how horrible it is when they are not followed that I knew how important they are
• We left that patient and his daughter in tears, confused, scared and hopeless
• Even if there was nothing that could be done for that man medically, we could have done a lot more to relieve his mental suffering and to make his death as comfortable as possible

Question 13

Effective communication

Explains the likely progress of a disease to a patient.

*

Answer 13

• Appendicitis during port elective
• Repeated admissions
• Frustrated by being bumped on emergency list
• Wanted to cancel surgery and go to Sydney to see her friends
• Advised her to raise concerns with surgeon
• My understanding that she would likely develop another episode
• High failure rate with antibiotics alone
• Risk of complications, more pain, another period away from work and in hospital
• She then asked about her appendix, what caused it to be inflamed, what happened in surgery
• Resulted in her deciding to stay
• Felt like I contributed to team

Question 14

Effective communication

Finds common ground with the patient in identifying the problem list, negotiating an evidence-based management plan and agreeing roles and responsibilities.

Answer 14

• Vaccination discussion in childrens health
• Paediatrician had organised a separate 1 hr appointment to discuss parents concerns
• His approach was based on a useful RACGP article organising parents along a spectrum
• Unquestioning acceptor to refuser with this mum being closer to the middle, vaccination hesitant
• This approach highlighted that where you sat on that spectrum was a function of your level of concern
• An unquestioning acceptor has done little to no research and has no concerns
• A refuser has also done little to no research but has major concerns
• The vaccination hesitant has done lots of research and this has made them concerned
• At each point along the spectrum, the parent is trying to do what they think is best for the child
• This point was raised early by the paediatrician, stating that he too wanted to do what was best
• That was not their point of disagreement. They only disagreed on what was in fact best
• The mum responded well to this point. I think people against vaccinations are often vilified and there is a kind of us vs them dynamic between doctors and anti-vaxers
• Finding the common ground that they both wanted what was best for the child diffused this tension and allowed the mum to trust the doctor enough to engage in a productive conversation about her specific concerns, which he could then address one by one
• From this I learnt to try to assume the best intentions from the patient as it will often be more productive
• Don’t just assume that the patient isn’t taking their statin because they’re lazy
• Assume that there is a very valid and understandable barrier to their compliance which needs to be overcome together, like intolerable side effects

Question 15

Social and cultural determinants of health

Plans health care with patients’ lifestyle, culture and resources in mind.

Answer 15

• 1 year old with epilepsy
• Presented after seizure
• Live about 1hr inland from Kempsey
• Mum had decided to drive son in instead of calling ambulance
• Reportedly drove well over 150kph because she thought her son was dying
• Because of the families remote location the decision was made to prescribe buccal midazolam in addition to usual first aid education
• The treating team hoped that this would allow the mum to be comfortable enough to call the ambulance and wait safely at home rather than endangering herself, her son, and other drivers by speeding on isolated country roads
• This was one of most influential cases that taught me the importance of considering the environment that you are discharging the patient back to
• Clearly, it would not have been appropriate to have proceeded with the standard care, with patient education on recovery positions and removing hazards etc
• The patient’s remoteness alone led to an additional prescription

Question 16

Social and cultural determinants of health

Recognises major public health problems and describes their determinants, distribution and prevention strategies; Identifies individuals at risk.

*

Answer 16

• My involvement with DEA has increased my awareness of the threat that climate change poses to public health
• WHO has declared it the single greatest threat to health in the 21^st century
• Its severity comes from its broad impact on all the major determinants of health
• Hygiene is impaired by increased floods, leading to more diarrhoeal disease, particularly cholera
• Rising temperatures increases the latitude that vector borne diseases such as malaria can spread, disproportionately affecting those who cannot afford preventative measures such as nets or enclosed housing
• Direct heat exposure will disproportionately affect the elderly and very young due to their physiology
• Increasing wildfires selectively affect those in rural and remote locations, destroying homes, land and livestock
• Worsening crop yields and decreasing nutritional content due to changes in soil composition will worsen nutritional deficiencies experienced by lower socioeconomic classes, particularly those that depend on subsistence farming
• It is a completely unequal problem. Its burden will be placed foremost on those who contributed to it least
• Every level of action, from the individual to the government can make a positive or negative impact but it is a truly global problem that requires effective policies to make good individual choices the easy, default decision

Question 17

Social and cultural determinants of health

Understands the current health status and health care needs of populations, including Indigenous people and other disadvantaged groups.

*

Answer 17

• I wanted to observe how the extreme socioeconomic and cultural differences between Australia and Zambia translated into divergent in health outcomes
• I believed this would help me understand how the significant differences in sociocultural circumstances between population groups within Australia result in such disparate health outcomes and care needs
• I was struck by how extreme the disease presentations were in Lusaka
• First time presentations with end stage diseases such as cirrhosis were the norm because patients did not have access to primary care facilities
• This was a more dramatic representation of what we see in rural Australia, with fewer doctors per capita and many remote communities living many hours from the nearest medical center
• Preventative medicine is simply not feasible under these conditions
• The impact of certain cultural beliefs in Zambia was clearly visible
• Most ward rounds there would be a patient with drug induced hepatitis because they had taken a herbal medicine prescribed by their villages healer
• A less obvious effect of culture is occurs every day in Australia with many aboriginal and torres strait islanders experiencing barriers to accessing health services because they are not seen as cultural safe or appropriate
• In all, my experience in Zambia showed my how impactful a patients sociocultural context can be on their health
• It taught me to consider these factors during all aspects of care
• Identifying sociocultural health determinants during my assessment of patients will help me form a more complete picture of the cause of their illness
• It will enable me identify factors that might interfere with their treatment
• it will help guide my formulation of an effective management plan that is appropriate to the patient’s circumstances.

Question 18

Social and cultural determinants of health

Collaborates with other health professionals in health promotion and disease prevention.

*

Answer 18

• In port Macquarie paediatric diabetes clinic, patients see a diabetes educator/dietician before paediatrician
• 14 year old girl with type 1
• Focus, priority and emphasis was entirely different between two professionals
• The diabetes educator was far more focused on the girls social context and how that was affecting her management
• She wanted to understand what was cool at school. What did her friends like eating. What sports were popular and what did she enjoy
• The paediatrician had an excel spreadsheet open on the computer and he spent the consultation discussing whether they needed to adjust how many units of insulin should be given per exchange
• Both approaches were entirely necessary and they complemented each other to deliver holistic care for this patient
• It taught me to appreciate and utilise the different expertise and priorities of different health professionals
• They will natural focus on different important aspects of the patients care
• Effective collaboration between various health professionals is the best method for ensuring that every aspect of care is optomised

Question 19

Social and cultural determinants of health

Familiar with the range of health and other social support services in the community and able to refer patients and collaborate appropriately.

*

Answer 19

• Zambia 76 year old with hepatocellular carcinoma
• Diagnosed with raised AFP
• Further steps in evaluation and management would need to be paid for privately by the patient
• As the patient could not afford this, the decision was made to palliate
• In the hospital, that man’s family was in charge of nursing him, changing his bed, toileting, feeding him
• They slept on the brick walkway outside the hospital every night
• This was extremely upsetting for me to witness
• I compared that to if the situation occurred in Australia
• The patient would have been completely covered by medicare
• The his management plan would have been guided solely by his functional status and tumour factors, not his financial status
• If the decision was made to palliate, this too would have been supported by the system
• A palliative care team would have overseen his care, ensuring his comfort, and he may have even been transferred to a specialist facility for palliation
• Growing up in Australia I have never questioned that this is almost a basic right
• We go well beyond basic health care
• Those that are elderly and frail can have a ACAT assessment
• A social worker can determine what level of supports they need to perform their adl’s
• Everything from shower rails to help with the gardening
• For chronic conditions like heart failure, a specialised nurse will round in the community, assisting patients in monitoring their daily weights and staying on top of their diet and exercise regimes
• My experience showed me just how important these services are in promoting good health and protecting against preventable diseases
• Habit of when formulating a patients management plan, consider what social aids may benefit their situation

Question 20

Ethics and legal responsibilities

Understands the law relating to health care, and applies this in a way that supports effective clinical practice.

*

Answer 20

• Difficult labour during OnG term
• Baby at shoulders
• Could not find fetal heart rate for 10 minutes
• Reg prepared for episiotomy but would not proceed until patient gave consent
• Patient was screaming and straining
• Had to ask repeatedly to get her attention
• I could hear the urgency in reg’s voice and yet she would not proceed until she got consent
• This stressed the importance of consent, and providing all the information necessary to make it informed, prior to things becoming urgent, like in this situation
• Because she had spoken to the patient earlier, all the reg had to do was ask if she could go ahead

Question 21

Ethics and legal responsibilities

Can identify inappropriate behaviour of self and others—from ethical and legal standpoints—and identify effective goals and strategies for overcoming these difficulties.

*

Answer 21

• 65 year old lady with disseminated TB
• 20 students crowded around her bed
• She was not asked whether she was happy to be involved in this bedside tutorial
• Without introducing himself to the patient, the consultant instructed the patient to sit up
• He listened to her chest from behind. Every time she rotated her head to see what he was doing he would forcibly rotate it back
• When he examined her abdomen she was diffusely tender
• She kept trying to stop him from pressing hard but he would force her hands away
• He then informed the group of her diagnosis and management plan
• We left without the patient ever being spoken to, confused and in pain
• This was an extreme example of what can occur when there is no respect for patient autonomy
• The consultants interacted with the patient as though she was a problem to be solved, not an autonomous being with her own concerns and expectations as to how this interaction should proceed

Question 22

Ethics and legal responsibilities

Recognises and responds appropriately to ethical issues in clinical medicine including complex interactions involving patients, their families and other care providers.

*

Answer 22

• 15 year old boy with hepatic encephalopathy
• clearly a type of status that came with being a doctor that made it socially acceptable, if not normal, for the doctors to be so paternalistic
• I could imagine that after years of dealing with that level of suffering I too might become detached as a means of coping
• This lead me to reflect on the fact that his actions were not intrinsically right or wrong
• In Australia, we value patient autonomy and beneficence
• therefore, the same actions in this context would appear immoral
• But in Zambia, that is not necessarily so
• Over there, the ethics were much more utilitarian – trying to make the little resources that they have go as far as possible
• As a result, the individual was less important
• Clearly, it is the changing context, with its cultural and social factors bubbling through, that make our actions right or wrong, not the actions themselves

Question 23

Ethics and legal responsibilities

Articulates personal and professional values and can demonstrate the manner in which these support the well-being of patients and others.

*

Answer 23

• Professional
  
  • Autonomy
  • Beneficence
  • Non maleficence
  • Justice
• Personal
  
  • Compassion
    
    • Earnestly wanting the best for others
• Professional ethics lay foundation and are first line for guiding a doctors action
• Core ethics often conflict with one another
  
  • Autonomy and beneficence in jehovas witness needing emergency transfusion
• Ultimately doctors are guided by balance of
  
  • Professional ethics
  • Personal values
  • Policies and practices prescribed by institutions
  • Behaviours displayed by role models
  • Practical limitations of context and environment

Question 24

Patient assessment and management

Collaborates with other health professional in management of patients with chronic and complex conditions, including Indigenous people.

*

Answer 24

• Mrs M chronic care plan patient
• IHD/diabetes/dyslipidaemia/HTN/osteoporosis
• GP chronic care plan with team care arrangement
• Allows her to access 5 allied health service session per year
• She used all of her sessions with the diabetes education/dietician
• In my assignment I noted that repeated appointments with a dietician improves glycaemic control compared to a single appointment at the initiation of treatment
• Her treatment may have been optomised by using some of the sessions on seeing her exercise physiologist more regularly, to get an individualised program
• I also noted that the practice that Mrs M attended had the GP, podiatrist and pharmacist all under the one roof
• Allowed for a degree of communication and collaboration that is not replicable over referral letters
• However, the podiatrist told me that much of this communication happened opportunistically
• It could have been improved by being more formalised, practice multi-disciplinary meetings

Question 25

Patient assessment and management

Demonstrates engagement with patients in shared decision-making and planning of their treatment, including communication of risk and benefits of management options.

*

Answer 25

• Mrs M chronic care plan
• Main issue while I spoke to her was lower limb oedema
• Several previous MI’s and HTN
• Heart failure noted on hospital discharge summary but not on problem list in chronic care plan
• Speaking to the GP, she was aware of the diagnosis, but Mrs M was not
• She recalled that the pharmacist had said her frusemide was to assist her heart
• This euphemism captured a significant disconnect between her primary concern and heart understanding of her own health issues
• The chronic care plan is supposed to be an opportunity for the patient and doctor to collaborate every year or every 3 months during a review
• Bring chronic issues to light that are less visible during regular consultations
• Cannot say why the GP did not list her heart failure
• It lead to her being mismanaged, with no first line therapies only frusemide, and poorly controlled with significant oedema
• May have been assumptions made as to how much Mrs M would understand
• Not listing the issue and discussing it removed the opportunity for Mrs M to share in formulating her management plan
• She may have been able to stress the importance of the odema and this would have led to a medication review

Question 26

Patient assessment and management

Identifies an agreed problem list with the patient that takes social, cultural, occupational and economic circumstances into account.

*

Answer 26

• Mrs M chronic care plan patient
• IHD/diabetes/dyslipidaemia/HTN/osteoporosis
• Pensioner from low socioeconomic background
• Recently gave up private health insurance because it became unaffordable
• Struggling to afford maintenance of car which she uses to get to her health appointments and gym classes
• GP chronic care plan with team care arrangement
• Allows her to access 5 allied health service session per year
• Her practice has GP, podiatrist and pharmacist all under one roof, lowering her cost of travel
• The public health system supported her during her several hospitalisations for IHD
• Her GP bulk bills her with no gap
• With a concession card, she makes a maximum co payment of 650 for her medications and has a safety net of 390 for the year
• Undoubtedly, these supports have extended Mrs M’s life and improved its quality
• It makes her critical therapies affordable, and things like the TCA make health promotion available to her, reducing the impact of chronic diseases like diabetes

Question 27

Patient assessment and management

Recognises typical and atypical features of a presentation.

*

Answer 27

• Medicine term
• Euglycaemic ketoacidosis
• Typical symptoms polyuria/polydipsia/nausea vomiting
• Gone to GP 2 days earlier and treated for UTI
• Monitored her BGL but didn’t rise
• Were 9.9 in ED
• Very vague and multi system presentation
• A VBG showed a high anion gap acidosis
• Reviewed her medications and found that she was on an SGLT-2 inhibitor
• Taught me to keep a broad differential and order investigations that will help sieve through them
• Seeing the acidosis was really the first clue that made sense of her presentation and prompted further interrogation of her medications which confirmed the diagnosis

Question 28

Patient assessment and management

Demonstrates sound clinical reasoning in responding to clinical problems.

*

Answer 28

• I was team leader during simulation in ED
• Patient with MI
• Became hypotensive
• We had had many scenarios before of dealing with distribution and hypovolaemic shock
• First cardiogenic shock
• Suddenly realised the dilemma with our usual approach with fluid boluses and pressors
• Increase strain on failing heart, worsen ischaemia and worsen hypotension
• Called a timeout and we discussed the issue as a group
• Decided to trial small fluid bolus and pressor, which luckily turned out to be correct decision
• Demonstrated importance of falling back on basic sciences when posed with clinical problem
• Calling for help early when faced with unfamiliar problem