Journal of Achievement Maya Aoude by MikeJenny

VIEWS: 19 PAGES: 40

									                  Rotation 4 2007




Journal of Achievement
Maya Aoude 40119412




                  Maya Aoude
                  Journal of Achievement
                  Rotation 4 2007

     Stanthorpe
Journal of Achievement                                                          Maya Aoude 40119412



Describe the rural community in which you lived during the rotation

Information such as population, geography, transport connections, population characteristics and the
local health care system should be included

Nestled in the picturesque Southern Downs and Granite Belt region, 250km south west of
Brisbane, on the New England Highway route to Sydney (Figure 1), Stanthorpe Shire covers an
area of approximately 2, 669 square kilometers. It is conveniently accessible from the
population centres of south east Queensland with daily coach services (1).




                                       Figure 1: Stanthorpe Location




The growing population in excess of 10, 600 enjoy a rich and diverse lifestyle. Half of the
population lives in the town of Stanthorpe, whilst the remaining population enjoys the best of
country living with easy access to the amenities of the town. The median age of people living in
Stanthorpe is 41 with 15% being born outside of Australia. 10% of Stanthorpe's population
speaks more than one language and 70% belong to the Christian denomination. More detailed
demographics of Stanthorpe are outlined in table 1 (2) (3).




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Journal of Achievement                                                                 Maya Aoude 40119412




                    Population and Socio Demographic Data – 2004
Population by sex
Total                                      10 592
Males                                      5 384
Females                                    5 208
Population : Percentage by age group
0-14 years                                 20.2%
15-24 years                                11.7%
25-34 years                                10.4%
35-44 years                                12.6%
45-54 years                                14.8%
55-64 years                                13.4%
65-74 years                                9.2%
75-84 years                                5.6%
>85 years                                  2.0%
Country of origin
Australia                                  86%
Italy                                      4%
United kingdom                             3%
Germany                                    1%
Family Statistics
Married                                    55%
Never Married                              26%
Widowed                                    8%
Divorced                                   8%
Religion
Catholic                                   37%
Anglican                                   24%
No religion                                12%
                         Table 1: Population and Socio Demographic Data 2004 (2) (3)




Stanthorpe is the coldest town in Queensland at an altitude of 924m, boasting four distinct
seasons and with around 50 days per year below zero degrees Celsius (1). I was lucky enough
to experience one of Stanthorpe‟s famous winters, affectionately known as Brass monkey
season with temperatures as low as minus 11 degrees Celsius.


The shire is home to 16 primary schools, 2 secondary schools, a TAFE campus, a 54 bed
hospital, 6 medical clinics, 2 dental clinics, child care and day care services, a nursing home,
retirement village and extensive sporting facilities. The Shire is also host to a comprehensive
library and Art Gallery complex, civic centre and museum. A complete list of services is outlined
in table 2.




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Journal of Achievement                                                     Maya Aoude 40119412


                                    General Services in Stanthorpe
                                                    54 beds
                                                    2 rural generalists
                    Hospital                        1 general surgeon
                                                    Visiting O&G, psychiatrist
                                                    Radiographer
            6 General practice clinics
                                                    14 hotels and motels
                Accommodation                       3 Caravan parks
                                                    >60 Hostels, B&B and cottages
                  Post office
                                                    Bendigo bank
                                                    Commonwealth bank
                    Banking
                                                    QLD credit union
                                                    National bank
                                                    Catholic church
                                                    Baptist church
                   Churches
                                                    Presbyterian church
                                                    Church of England
                                                    Playing fields
                                                    Swimming pools
                                                    Gymnasium
                                                    Golf club
                                                    Bowls club (indoor and outdoor)
                                                    YMCA
                                                    Orienteering
                                                    Squash club
               Sporting facilities                  Tennis association
                                                    Gun club
                                                    Pistol club
                                                    Archery club
                                                    Jockey club
                                                    Pony club
                                                    Skate bowl
                                                    Choir
                                                    Concert bands
                                                    Daily coach services between Stanthorpe and
                                                    Brisbane
                   Transport
                                                    Bus services between Stanthorpe and Warwick
                                                    Taxis


                                Table 2: General services in Stanthorpe

The first European to explore the area was Allan Cunningham who passed through the area in
1827 (4). However, it remained a lonely outpost until the discovery of tin on the Quart Pot Creek
in 1871 brought an influx of miners to the area. The coach station became a regular stopover
point for Cobb & Co and the town grew quickly (4). It was around this time that the fruit growing
potential of the area was realised. Whilst the mining boom petered, it was the fruit growing
industry which provided the solid foundation for the growth of the shire, with the region now



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Journal of Achievement                                                             Maya Aoude 40119412



supplying a substantial portion of the State‟s fresh fruit and vegetables and exports interstate
and overseas.

Stanthorpe‟s primary tourist attraction is without a doubt it‟s many wineries; 640 ha of wine
grapes are produced and sold from the 52
wineries/vineyards. An astonishing 100 tonnes of grapes
are crushed in Stanthorpe each year. It is estimated that
between 200 000 and 250 000 people visit the region
annually spending an average $25-30 million (4).


Extensive areas of National Park along the southern
border areas of the Shire, containing the famed
Girraween and Sundown National Parks are added
attractions for those who appreciate the rugged natural
landscape (figure 2).
                                                                                 Figure 2: Bald Rock

Medically, Stanthorpe is relatively well supplied, in term of facilities given the size of the town.
However, from a staffing perspective, the town is relatively poorly serviced. I spent my six
weeks evenly between a general practice clinic and the hospital. Medical services are
outlined in table 3.

                                               Medical facilities
                                                        54 Beds
                                                        General medicine
                                                        Basic general surgery
                                                        Maternity ward
                                                        Aged care
                                                        Emergency department
                                                        Outpatients
                     Hospital
                                                        Palliative care
                                                        Allied Health (Radiography, Physiotherapy,
                                                        Occupational therapy)
                                                        Community health services inclusive of child health
                                                        Social workers
                                                        Mental health workers
                                                        Oral health
               Visiting Specialists                     O&G, psychiatrist
                                                        Dental -2
                 Clinics available
                                                        General Practitioners - 6
                                                        Physiotherapy
              Allied health services                    Social work
                                                        Occupational therapy
              Other aged services                       Long stay patients. Aged care assessment team
                Nursing Home
                   Hospice
           Other community services                       Blue care
                                     Table 3: Medical facilities in Stanthorpe




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Journal of Achievement                                                             Maya Aoude 40119412



Analyse the health care needs of this community
Where relevant, prioritise the health needs from most to least important, indicating the reasons for relative
importance. Indicate whether or not these are dealt with well, Identify any particular strengths or
constraints that affect how well health care is delivered.

The main health care needs in the Stanthorpe community relate to access: Access to specialist
medical care; access to complicated radiological studies, and; access to emergency surgeries.
These problems can only be overcome by having specialist medial services and equipment
within Stanthorpe which is obviously not a realistic goal. In terms of achievable outcomes,
therefore, the needs of the Stanthorpe community are largely relating to staff and education.

The most important health concern for the residents in and around Stanthorpe is skin cancer
and its prevention. Skin cancer places an enormous burden on Australia through morbidity and
financial costs. More than 370 000 Australians are diagnosed with non-melanoma skin cancer
annually. In addition over 2 300 Queenslanders are diagnosed with invasive melanoma each
year. The treatment cost of non-melanoma skin cancers amount to more than $250 million each
year (5). Skin cancer is a major public health problem for Australians, specifically those working
„on the land‟.

Stanthorpe hosts a high prevalence of outdoors employment within its large orchard and wine
industry. Many people of rural Australia do not give sun safety a second thought in their younger
years as they believe they are invincible. Furthermore, a subsection of rural Australians hold the
view that skin cancers are nothing but a trivial nuisance and are simply the price one pays for
living and working “ on the land”.

This particular health issue is dealt with poorly in Stanthorpe. It has been my experience that in
previous years there has been very little education in regards to sun safety. Many of the older
patients were unaware of the dangers of sun exposure growing up. Hopefully with increasing
education in schools there will be a decrease in skin cancer presentations. Furthermore, whilst
general practitioners become experts at skin lesions after working in the Country for a period of
time, it does not compare to the expertise of a dermatologist, with the closest dermatologist
located in Toowoomba. There is a need to further emphasise the slip, slop, slap message and
that prevention is the key.

There is a high prevalence of mental health issues in Stanthorpe especially coinciding with the
recent drought. Characteristics of small town life can negatively impact on mental health. Rural
areas suffer fewer mental health facilities and social services, poorer education, fewer avenues
of entertainment for young people, higher levels of stress and unemployment leading to a lower
socioeconomic status as well as a lack of anonymity and confidentiality due to a greater
closeness of relationships among community members.

During my stay in Stanthorpe I came across many patients living with depression that either
received sub optimal treatment or were in denial. On the whole, mental illness remains
stigmatized within Stanthorpe with the view that it is a sign of weakness. Untreated, the problem
escalates with suicide eventually viewed as the only available release. Suicide rates in rural
areas (43/100000) have been shown to be double that of urban areas in 1997 (24/100000) (6).




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Journal of Achievement                                                     Maya Aoude 40119412



Education of both medical staff and the community is needed in regards to mental illness.
Whilst the government is taking small steps to rectify this, no outwards signs of progress are
visible.

On the whole Stanthorpe is relatively well serviced, with staffing and education being the
greatest obstacles.




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Journal of Achievement                                                                Maya Aoude 40119412



Describe the difference between urban and rural practice
The Australian college of rural and remote medicine defines rural and remote medicine in the following
way: Rural and remote medicine operates on a unique paradigm of primary, secondary and tertiary
medical care, with increased responsibility (for the practitioner) owing to the relative professional isolation,
geographic isolation, limited resources and special cultural and sociological factors.

The rural or remote medical practitioner requires a broad understanding of diagnosis, treatment and
management from the perspective of a number of medical and surgical disciplines and applies these skills
along a continuum of care from primary presentation to secondary and sometimes tertiary care.
Practitioners are able to adapt and build their skills in response to the health needs of a diverse range of
rural and remote community settings and the degree of isolation from other health services and
resources.

The defining features of rural health services compared to urban health services are reduced
access, choice and options, with further to travel to receive medical attention, less choice of
general practitioners and fewer visits per annum. Rural health services also experience
considerable difficulties attracting adequate numbers of well-trained nurses and allied health
professionals.

The clinical management of most diseases is the same across Australia, irrespective of location.
However, who manages these conditions, under what circumstances and with what resources
varies. Rural practitioners carry a heavier workload and provide a wider range of services,
including, anaesthesia, procedural obstetrics and emergency medicine then their urban
counterparts.

Diagnostic modalities are difficult to justify in many cases in metropolitan centres. Investigations
are ordered to “cover all bases, and thoroughly exclude severe causes of patient‟s
presentations. Often the economics of these decisions are brought into question. To accurately
diagnose a patient in rural Queensland, not only are many of these tests required as they would
be in a major centre, the various pathology samples must first be taken and processed in a
larger centre. This involves infinitely more financial burden to the health budget than most would
consider. Moreover, many tests are simply not available without transporting the patient even
further afield. One such example I experienced was a young lady who presented with calf
tenderness, redness and swelling, whilst the most likely diagnosis was a DVT the facilities were
not available to perform the ultra sound and lady had to be transferred to Toowoomba. This
clearly affects the doctor and the patient.

For these reasons and many more, it is vital that the rural practitioner not rely on traditional
means of diagnosis and management that require facilities and infrastructure that may be
financially and functionally available in urban areas but are unfeasible in smaller rural towns.
Instead he/she must rely on clinical acumen, have the skills to perform procedures that might
otherwise require referral to specialists and have the ability to decide when a patient does
indeed need transport to a larger centre.

Despite its many downfalls, the majority of rural practitioners are passionate about their work,
love the country atmosphere and choose to be here. The reasons for this are as many and
varied as they patients that they see. The work is diverse and constantly changing, reducing the
likelihood of boredom or monotony. Patients see their doctors as their lifeline in emergency
situations, and to a large extent appreciate the difficulties associated with the remote lifestyle.
For this reason and others, Patients are greatly appreciative of rural doctors. This, combined
with the increased continuity of care that rural doctors provide for their patients leads to a
rewarding, therapeutic relationship that is incredibly hard to achieve in a larger centre.


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Journal of Achievement                                                             Maya Aoude 40119412




As can be seen, the differences between urban and rural practice are extensive and by no
means exhausted here




Bibliography


1. Holidays, Queensland. Stanthorpe - Places to visit. Queensland Holidays. [Online] Queensland
Government, 2007. [Cited: August 12, 2007.] www.queenslandholidas.com.au/destinations/south-east-
queensland-country/placestovisit.

2. Statistics, Australian Bureau of. National Regional Profile: Stanthorpe. Australian Bureau of Statistics.
[Online] Australian Government, November 20, 2006. [Cited: August 17, 2007.]
www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/LGA36600Population/.

3. Estate, Domain Real. Stanthorpe Suburb Profile. Domain. [Online] Domain, 2007. [Cited: August 18,
2007.] www.domain.com.au/Public/suburbprofile/Stanthorpe.

4. Australia, Walkabout. Walkabout Australian Travel Guide to Stanthorpe. Walkabout Australian Travel
Guide. [Online] Fairfax, 2007. [Cited: August 18, 2007.]
www.walkabout.fairfax.com.au/smh/fairfax/locations/QLDStanthorpe.shtml.

5. Welfare, Australian Institute of Health and. Skin Cancer Statistics. Australian Institute of Health and
Welfare. [Online] Australian Government, 2006. [Cited: August 18, 2007.]
www.aihw.gov.au/mediacentre/1998/mr19981003.cfm.

6. Moon, L, Meyer, P and Grau, H. Australia's Young People: Their health and wellbeing. Canberra :
Australian Institute of Health and Welfare, 1999.




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Journal of Achievement                                                        Maya Aoude 40119412



Case 1: An Urgent Referral

Visit 1

Presenting Problem:

Mr. B, a 61 year old farmer, presented with constant palpitations and chest pain. His palpitations
had been periodic and were generally well controlled until recently where he recounts a 6 week
period of increased awareness of palpitations.


History of Presenting Complaint:

         Palpitations present for the majority of the day over the last 6 weeks
         Chest pain present only on 2 occasions – dull pain, located centrally, brought on by
          excessive farm work, no radiation, relieved by rest
         Increasing tiredness
         No associated shortness of breath
         No previous history of chest pain
         No previous history of respiratory problems
         Non smoker


Past Medical History:

         No significant past cardiovascular history apart from periodic palpitations
         Hypercholesterolemia
         Peptic ulcer/GORD – tested positive for Helicobacter pylori
         27/04/07 – Influenza vaccination



Past Surgical History:

         None



Allergies:

         None



Medications:

         Ducene (diazepam) 2.5mg PRN
         Nexium 40mg/daily
         Lipitor 40mg/daily



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Journal of Achievement                                                        Maya Aoude 40119412



Family History:

      No significant family history was obtained


Social History:

      Married farmer, living with his wife on a property 30 minutes out of Stanthorpe town with
       no immediate access to medical attention.



Risk Factors:

      Male
      Age
      Hypercholesterolemia



Examination:

      BP: 130/90.
      Pulse: 68 and regular.
      No added heart sounds.
      Apex beat located in the 5th intercostal space, mid clavicular line.
      No peripheral signs of cardiovascular disease.



Investigations:

      ECG: Sinus rhythm with supraventricular ectopics present.



Provisional Prognosis:

      Non STEMI
      Angina
      GORD
      Anxiety
      Premature ectopic beats
      Paroxysmal tachycardia




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Management:

      Urgent referral to cardiologist
      Patient started on Tambocor (flecanide) 50mg bd
      Patient given pathology slip for routine blood test before return to GP



Visit 2:

Mr. B, presented with a letter from his cardiologist and to obtain his results from the blood tests.
ECG and stress test were performed by the cardiologist ruling out any ischaemic cause of the
palpitations. A heart rate of 135bpm which is 85% of age predicted maximum was achieved by
Mr. B and at no time did he develop chest pain, arrhythmias or ST segment changes. The
cardiologist recommended Mr. B continue on the Flecanide. Furthermore, Mr. B was advised to
present to his local hospital if he had recurring chest pain. The pain may have been due to
GORD and the palpitations benign.

Mr. B‟s blood tests revealed increased calcium. Repeat bloods were performed looking at intact
PTH molecule.



Visit 3:

Mr. B‟s blood tests revealed elevated calcium and intact PTH. The results are displayed in table
1. Mr. B was referred for an ultrasound of his thyroid and parathyroid.

                                01/07/2007               12/07/2007                03/08/2007
Intact PTH (14 -72ng/L)            N/A                       120                      N/A
Calcium (2.25 -2.65                2.69                     2.62                      2.61
mmol/L)
Corrected Calcium                   2.84                     2.73                      2.69
(2.25-2.65 mmol/L))
Albumin (35-50 g/L)                 38                       39                        40
Phosphate (0.8-1.5                  0.9                      1.0                       0.8
mmol/L)
Table 1: Serum calcium and PTH results for Mr. B.




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Provisional Prognosis:

      Primary hyperparathyroidism due to:
            o 80-85% caused by solitary adenoma
            o 15-20 % hyperplasia of all glands
            o <0.5% parathyroid carcinoma
      It is possible the hyperparathyroidism was the cause of the palpitations. “About 5-6% of
       patients with parathyroid disease over the age of 50 will discover their parathyroid
       disease after they present to the emergency room with palpitations. Removing the
       tumour will almost always cure the palpitations.” (1).
      It is possible the GORD was the cause of the chest pain.


Progress:

      Ultrasound:
           o 1.4cm hypoechoic lesion in the location of a parathyroid gland  correlation with
              PTH and serum calcium levels recommended – patient may require assessment
              with sestamibi nuclear medicine examination
           o Incidental finding of a dominant solitary nodule in the mid aspect of the left lobe
              of the thyroid measuring 1.5 X 1.1 cm  FNA suggested
      Parathyroid study –Technetium labeled Sestamibi study
           o To identify the site of a possible parathyroid adenoma in view of Mr. B‟s raised
              PTH levels and serum calcium levels.
           o The neck and thoracic region were imaged 15 minutes and 3 hours after injection
           o Findings: Clearly demarcated area of non thyroidal increased metabolic activity
              lying posteriorly to the mid pole of the left lobe of the thyroid gland (figure 1). In
              view of the elevation of the parathyroid hormone and serum calcium this is
              almost certainly due to a single parathyroid adenoma.
      FNA of thyroid: Ultrasound with surgical procedure:
           o Nodule in the mid left thyroid lobe measuring 2 x 0.9 x 1.4cm – under ultra sound
              guidance 3 passes were made with a 22 gauge needle. The specimen was
              plated and sent to S&N for cytology.
           o Findings are consistent with cystic degeneration, however, the nature of the cyst
              cannot be determined from this specimen. Follow up is recommended with
              aspiration if lump reoccurs.




                               Figure 1: Sestamibi scan of parathyroid tumour

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Diagnosis:

      Parathyroid adenoma. The patient is currently awaiting surgery to remove the
       adenoma. In the mean time Mr. B has been informed to:
            o Increase fluid intake to prevent stone formation
      Avoid thiazides and high calcium intake
      It is important to perform a bone scan to check for osteoporosis as a result of his primary
       hyperparathyroidism.



Rural Issues:

      Access: The majority of the tests Mr. B required were not available in Stanthorpe. Mr. B
       was forced to travel to Toowoomba and Brisbane on numerous occasions and is still
       awaiting surgery in Brisbane. Furthermore, had the initial symptoms been those of a
       myocardial infarct, Mr. B would have had no access to thrombolysis or angiography.




Learning Issues:

      Chest pain + Palpitations, with significant risk factors require urgent referral.
      The severity and type of symptoms associated with hyperparathyroidism are not related
       to how high the calcium levels are. As can be seen with Mr. B, his calcium levels were
       only slightly elevated. A slight elevation which may have been very easy to overlook.
      Hyperparathyroidism can cause GORD/peptic ulcer, palpitations and tiredness (2). It
       would be interesting to see if Mr. B‟s GORD, palpitations and tiredness settle once he
       has had his parathyroid adenoma removed.
      Sestamibi scan is the preferred way to localize diseased parathyroid glands prior to an
       operation. Sestamibi is a small protein which is labeled with technetium-99. This
       radioactive agent is injected into the veins and absorbed by overactive parathyroid
       glands. As normal parathyroid glands are inactive when there is high calcium in the
       blood stream they do not take up the radioactive particles (1).




Bibliography


1. Clinic, Doctor John Norman - Norman Endocrine Surgery. Parathyroid disease. [Online] 2007. [Cited:
August 19, 2007.] www.parathyroid.com.

2. Kumar, Clark. Clinical Medicine. London : W.B Saunders



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Journal of Achievement                                                    Maya Aoude 40119412



Case 2: Mental Health

Presenting Problem:

Miss A, a 19 year old, unemployed single mother of one, presented to the GP complaining of
lower back pain. Throughout the course of the consultation it was identified that Miss A had
attempted suicide on two occasions in the last week and was very keen to see a psychiatrist as
she did not want to lose her daughter.



History of Presenting Complaint:

      Lower Back Pain:
          o Present throughout the majority of the day for the last year since the birth of her
             daughter.
          o Was not relieved by any medications but was relieved by smoking marijuana.
      Mental Health:
          o The patient smokes 4-5 cones of marijuana every night in order to enable her to
             sleep. However, the patient stated she had never smoked pot in front of her
             daughter.
          o Patient states she has been depressed – poor appetite, poor sleep (except if she
             smokes marijuana). This has been exacerbated since the break up with her
             partner of 7 years 2 months ago.
          o Patient reports visual and auditory hallucinations telling her to kill herself
          o Patient has been very paranoid.
          o Patient attempted suicide on 2 occasions in the last week:
                  First occasion: by hanging
                  Second occasion: jumping off Stanthorpe bridge
          o Miss A did not follow through with either attempt as she thought of her daughter
             and could not bear the thought of leaving her orphaned. Miss A has sworn she
             no longer has any suicidal ideation.
          o Miss A states she believes she is having anger management problems, claiming
             to have hit her head against the wall on numerous occasions in order to relieve
             her frustration. On further questioning Miss A indicates that neither her nor her ex
             partner have been violent towards their daughter, nor would they ever be.
          o Miss A is very keen to get some help from psychiatrist/psychologist, but does not
             want any medications.


Past Medical History:

      Diagnosed with depression and schizophrenia at the age of 7, Miss A saw a psychiatrist
       for one year and was put on medications. Patient is unable to remember what these
       medications were as she has not taken them for the last 10 years.




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Journal of Achievement                                                    Maya Aoude 40119412



Past Surgical History:

      None



Allergies:

      None



Medications:

      None



Family History:

      Miss A is unaware of any significant family history as she has not had any contact with
       her family since she left home at the age of 12.



Social History:

      Lives with her daughter aged 1 in a unit at Stanthorpe
      No family contact
      Currently separated from partner
      Currently unemployed – previous work as a farmhand
      2 close friends in Stanthorpe
      Left school at age of 13
      Left home at the age of 12. Lived on the streets of Rockhampton for 2 years where she
       met her previous partner. Together they moved to Stanthorpe where they managed to
       find work and hire a unit.
      Used various illicit drugs until 2 years ago.
      Smokes up to 1 pack of cigarettes per day
      Regular marijuana use
      Binge drinking 1-2 times a week


Risk Factors:

      Depressed/irritable mood
      Feelings of worthlessness
      Fatigue
      Recurrent thoughts of death/suicide


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      Anger management problems
      Becoming pregnant early in life
      Previous suicide attempt
      Poor socioeconomic status
      Increased alcohol and drug use
      Lack of connection to family and friends


Examination:

      General appearance: slightly disheveled but with clean clothes and good hygiene
      No apparent thought disturbances
      Appropriate affect
      No single point of tenderness was detected on examination of the lower back
      No abnormality in range of movement of spine was obvious


Investigations:

      Pathology slip for STD screen



Provisional Prognosis:

      Depression
      Recurrence of schizophrenia
      Back pain most likely due to depression but appointment with physiotherapist was made


Management:

      Referral to physiotherapist
      Patient refused any medication
      Better Access Mental Health Care plan was drawn up, with the patient eager to start
       seeing a psychiatrist as soon as possible. Patient did not want to be admitted into
       hospital and on careful examination and consultation with a psychiatrist it was believed
       safe to send Miss A home, with an appointment made to see the visiting psychiatrist the
       following day (it was Miss A‟s luck that the psychiatrist was present in Stanthorpe the
       following day).
      Miss A was informed of the dangers of smoking marijuana, and with assistance is open
       to possibly cutting down.
      Miss A was provided with contact phone numbers should she feel suicidal or unable to
       cope.
      All parties were satisfied with the outcome pending review with psychiatrist tomorrow.




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Journal of Achievement                                                      Maya Aoude 40119412



Progress:

      No further information was obtained in regards to Miss A, as my placement with the GP
       ended.


Rural and Population Health Issues:

      Increased rates of depression and suicide amongst young people in rural areas.
       Suicide rates have been shown to increase with increased remoteness, with suicide in
       rural areas (43/100 000) almost doubling that of urban areas in 1997 (24/100 000) (1).
      Access: Rural areas suffer fewer health and social services, poorer education, fewer
       avenues of entertainment for young people, higher levels of stress and unemployment
       as well as a lack of anonymity and confidentiality due to a greater closeness of
       relationships among community members (2). There is no permanenet psychiatrist
       within Stanthorpe. There is only a visiting psychiatrist who holds a clinic one day every
       fortnight. Had it been decided that Miss A should be admitted to a mental health facility
       immediately, she would have required transport to Toowoomba. Therefore, whilst this
       particular patient may have been admitted to a mental health facility in a larger city, it
       was not feasible to do so in Stanthorpe. Admitting Miss A would have meant taking her
       away from the only protective factor she had, her daughter.
      Attitudes: Whilst generalizations are generally not valid, it has been my experience that
       Miss A has not been welcomed into rural life by the local community. This may
       contribute to her feelings anxiety, depression and paranoia, as she feels everyone is
       talking about her. These factors lead to the inability of Miss A to live harmoniously in the
       community.
      Employment: Employment is difficult for Miss A to achieve in Stanthorpe, compounded
       by her apparent lack of rurally relevant skills and the need to care for her 12 month old
       daughter.


Ethical Issues:

      Do no harm: Was sending Miss A home the right decision? In order to answer this
       question one needs to consider the benefits of her being in hospital versus the benefits
       of being at home. In the end it was felt that Miss A was best of with her daughter (who
       was her only protective factor), on the condition that she saw a psychiatrist the following
       day. Miss A‟s daughter was also a patient of the clinic and was always well dressed,
       healthy and well looked after. It was not felt that Miss A was a danger to her daughter in
       anyway.
      Autonomy: Right to choose to go home and not be on any medications – is she
       competent to make her own decisions? Is she a danger to herself or others? In the end it
       was felt that Miss A was competent to make her own decisions and had insight into her
       situation. Miss A was determined to get help.


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       Beneficence ‘Do Good’: Are we doing what is in the best interest of the patient and her
        daughter? In this case it was felt that more harm would occur had the patient been taken
        away from her daughter and placed in hospital.
       Justice: equality – access to mental health facilities. There is a lack of psychiatrists and
        other mental health facilities within Stanthorpe. This indicates a lack of justice for the
        citizens of Stanthorpe living with mental illness.




Learning Issues:

       There are increased rates of depression and suicide amongst young people in rural
        areas.
       Many of the risk factors that contribute to depression and suicide among young people
        are more prevalent in rural areas. It is believed that at least part of the cause for the
        large discrepancy between rural and urban suicide rates is due to an increased
        prevalence of mental health issues in rural areas. One study which looked at the health
        concerns of rural vs. urban youth in Australia found that youth suicide was identified far
        more readily as a concern of rural youth then those in urban areas (3). Another major
        factor in youth suicide is poor socioeconomic status amongst those in rural areas. These
        are all factors which may be applied to Miss A.


Bibliography


1. Moon, L, Meyer, P and Grau, H. Australia's young people: Their Health and Wellbeing 1999.
Canberra : Australian Institute of Health and Welfare, 1999.

2. Toward understanding youth suicide in an Australian rural community. Bourke, L. s.l. : Social Science
and Medicine, 2003, Vol. 57.

3. Health and access issues among Australian adolescents: a rural-urban comparison. Quine, s, et al.
245, s.l. : Journal of Rural and Remote Health, 2003, Vol. 3




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Case 3: A Respiratory problem and an urgent referral – for assessment



Presenting Problem:

Mr. T, a 61 year old builder, presented to hospital on 08/08/07 with SOB, productive cough
(white sputum) and fever over the last 2 days, with a 40 pack history following referral by his
GP. Mr. T also reported urinary urgency over the last week.



History of Presenting Complaint:

      SOB started 2 days ago with exertion and progressed to SOB at rest over the last day.
       Prior to this Mr. T was relatively fit for his age with good exercise tolerance.
      No history of URTI, chest pain, wheeze, asthma, COPD or overseas travel.
      40 pack year history
      Increased frequency of urination – patient reported waking up in the night needing to
       void. However, no dysuria was present.


Past Medical History:

      Bronchitis in the winter
      Hypertension – well controlled
      Rheumatic fever at age 11
      Fall from roof 12 years ago
           o Pelvic, thoracic and cervical fracture
           o Spinal stenosis – PRN pain relief
           o Numbness in legs – mobility problems, requires a walking stick



No significant past surgical history



Allergies:

      Penicillin – facial oedema



Medications:

      Avapro HCT
      PRN tramal SR and quick release




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No significant family history


Social History:

      Lives at home with his wife
      Smoking: 40 pack year
      Alcohol: 8-10 beers/week


Examination:

      Severely dyspnoeic on 6L oxygen, use of accessory muscles and barrel chest
      BP: 150/90, RR: 34
      Pulse: 105 and regular
      Air entry decreased bilaterally with inspiratory crackles L middle and lower zones.
      Percussion normal and equal bilaterally
      not cyanotic, no tracheal tug or deviation, no stridor, no wheeze
      Heart sounds dual - no added heart sounds
      Apex beat located in the 5th intercostal space mid clavicular line
      No peripheral signs of cardiovascular disease



Investigations

      CXR
      Spirometery
      Ward urine test
      BSL = 7.1


Provisional prognosis:

      Pneumonia
      Emphysema
      Asthma


Management:

      Admit to the ward on oxygen with full observations
      Full diet
      IVC – IV antibiotics
      Antibiotics: Rulide 300mg bd, Ceftriaxone 1g bd



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      Nebulised ventolin
      Continue normal medications


Progress:

      Continued oxygen therapy with good oxygen sats – patient feels condition is improving
      Ward urine test showed small blood, protein +++




09/08/07:

09:00: Ward round

      Patient states he is feeling much better, but still requiring oxygen
      Patient is stable on 3L oxygen, afebrile, crackles throughout the lungs but good air entry
      Continue observations and management plan
      Patient counselled on smoking cessation and willing to try


21:15: On call doctor called to review patient

      Issues:
          o Respiratory distress: Increased work of breathing, RR = 32, decreased air entry
              globally, expiratory wheeze
          o New onset AF: HR increased 120-180, irregularly irregular, BP = 150/100, no
              chest pain.
      Investigations:
          o Troponin: negative
          o CXR: no consolidation, no pneumothorax, mild overinflation
          o ECG: new onset AF + interventricular delay, ?mild ST elevation
      Management:
          o 5mg morphine
          o 40mg frusemide
          o 300mg aspirin
          o 5mg ventolin repeated 3 times every hour + atrovent
          o 100mg hydrocortisone
          o Patient moved to a monitored bed, given high flow oxygen
          o Amiodarone infusion
          o Serial ECGs, TnI, ABG requested one hour after amiodarone started


23:00: Half way through amiodarone infusion

      HR = 160, oxygen saturation = 99% on high flow oxygen
      Laboured breathing (slightly improved), patient sweaty
      ABG: pH = 7.13, pCO2 = 108, pO2 = 92, HCO3 = 35




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23:30

       Issues:
           o Rapid deterioration in condition: breathing laboured and patient less responsive
           o Increase in diastolic BP and diaphoresis
           o Patient unresponsive
           o Intubation
           o Patient in VF following intubation, HR = 150-160
       Management
           o Amiodarone ceased
           o Patient intubated and connected to oxylog
                  Oxylog – SIMV rate 12 1:3, FiO2 100%
           o Defibrillation at 200J  returned to sinus rhythm
           o Patient sedated with morphine and midazolam infusion
           o 5mg IV metoprolol given  HR returned to 100
           o IDC inserted
           o NG tube inserted
           o CXR – to confirm tube placements
           o Call made to retrieval team
       ABG: pH = 7.121, pCO2 = 105, pO2 = 104, HCO3 = 35




00:30

       Issues
           o Respiratory acidosis
           o CXR confirmed ETT, NG tube and no worsening of chest appearance
       Management
           o Oxylog rate increased to 20
       ABG: pH = 6.85, pCO2 >130, pO2 = 266




01:30

       ABG: pH = 6.70, pCO2 >130, pO2 = 151
       ECG: ST elevation in anterolateral leads
       Troponin: 0.16




0530: Patient airlifted to Redcliffe hospital

       Issues:
           o Respiratory failure secondary to COAD, requiring intubation
           o Infective exacerbation of COAD
           o Fast AF


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         o Episode of VF reverted to SR with one shock
      Medications:
         o Avapro HCT
         o Ceftriaxone 1gm/daily
         o Rulide 300mg orally
         o Hydrocortisone 100mg QID
         o Salbutamol and atrovent nebulisers




10/08/07

Redcliffe hospital – on admission

      Issues:


           o  Patient unresponsive – GCS = 3, pinpoint pupils, no reflexes present
           o  BP = 88/58, HR=95, cool periphery, dual HS, no peripheral oedema
           o  Lungs: crackles at R base
           o  Abdomen: soft and non tender, bowel sounds present
           o  Haemodynamicaly unstable – hypoperfusion with mixed respiratory and lactic
              acidosis
      Investigations:
          o Troponin: TNI leak – in setting of renal failure
          o CXR: early change RLL consolidation, hyperinflation
          o Abnormal LFTs: AST = 392, ALT = 302, ALP = 81, gamma GT = 189
          o Renal creatinine: 153
          o Hb = 149, HCT = 0.47, platelets = 82
          o Coagulation = normal
      ABG: pH = 7.20, pCO2 = 66.6, pO2 = 542, HCO3 = 27.3, Base excess = -1
      Impression:
          o Hypercapnic respiratory failure
          o Acute renal failure
          o Thrombocytopaenia – early DIC?
      Management:
          o Patient ventilated
          o Femoral line inserted
          o Morphine reduced slightly – reassess CGS
          o NA 8mg/hour
          o Repeat bloods, TNI, CK
          o CXR
          o SIMV – aim: SPO2 > 94%, PaO2 = 70-80, PaCO2 <50
          o IV fluids + albumin – wean of NA
          o Ceftriaxone + Azithromycin
          o Ventolin, atrovent, prednisolone
          o Start NG feeds




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Progress:

      During his 4 week stay in Redcliffe Mr. T‟s condition worsened and he was found to be
       positive for Influenza A.
      Week One: In the first week, as a result of his worsening acidosis and increasing
       respiratory distress Mr. T had a percutaneous tracheostomy inserted. Mr. T had further
       medical issues in that his AF did not resolve and he developed acute renal failure with a
       creatinine of 214 and decreased urine output. An echocardiogram showed Mr. T had
       moderate aortic stenosis.
      Week Two: Following an increase in his amiodarone to 150mg and his maintenance
       fluids to 50ml/hour inconjunction with potassium replacement Mr. T‟s renal function and
       AF began to improve slightly. However, Mr. T became hypernatraemic (Na = 150) and
       complained of constipation, investigation of which revealed dilated loops of bowel for
       which he was given neostigmine. The following day Mr. T developed new onset pyrexia
       (39.1oC) and he was placed on empirical vancomycin. A septic screen of his tracheal
       aspirations, urine and stool found nothing. The fever was put down to the development
       of paralytic ileus which was confirmed by abdominal CT. Furthermore, there was
       difficulty weaning him of his tracheostomy due to problems with:
            o Bronchospasm
            o LVF due to valvular heart disease – AS
            o Encephalopathy/agitation due to his long standing respiratory acidosis
            o Abdominal distension.
      Week Three: An ECG revealed a more prominent LBBB and there was a small increase
       in troponin (0.1) indicating possible heart strain or NSTEMI. In an attempt to counteract
       this Mr. T was started on digoxin and his dose of ACEI increased. Mr. T continued to
       demonstrate signs of encephalopathy with no respiratory changes. However, on the
       bright side Mr. T‟s sodium levels and renal failure had returned to normal and his
       antibiotics, steroids and potassium were ceased.
      Week Four: It was discovered that Mr. T has a tracheostomy leak but appeared to be
       ventilating spontaneously. Mr. T was trialed on a T piece. Although originally Mr. T had
       some mild respiratory difficulty he continued to progress well. Following speech
       pathology review Mr. T was also restarted on an oral diet. This week also saw Mr. T‟s
       bowel movements return. By the end of the week Mr. T was up reading and mobilising
       and on a full diet. However, he still had ongoing AF at a rate of 95 and his sputum and
       urine cultures had grown pseudomonas aeruginosa for which he was re started on oral
       antibiotics. His blood cultures were negative. Overall, it was decided Mr. T was ready for
       discharge and he was sent back to Stanthorpe hospital for rehabilitation on 31/08/07.
      Patient readmitted to Stanthorpe hospital as a back transfer from Redcliffe hospital.
       On arrival Mr. T, had nil complaints and was settled. Observations showed T=36.6, HR =
       92, RR=22, BP = 120/62, SpO2 of 93% on RA. Mr. T was mobilising well with nil ooze at
       his trachy site. Ward test urine showed large blood and leukocytes, and a MSU was
       collected which grew pseudomonas aeruginosa. However, as the patient was
       asymptomatic no further action was taken. Mr. T was started on heparin and warfarin for
       his AF and as there were no further medical issue he was allowed leave for lunch or a
       couple of hours everyday whilst his desired INR levels were achieved. Following
       successful warfarin dosing Mr. T was eventually able to go home on 07/09/07. Mr. T
       was discharged on the following medications:
            o Atorvastatin 20mg nocte
            o Spironolactone 25mg daily
            o Amiodarone 200mg mane



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           o    Captopril 50mg tds
           o    Salbutamol 5mg QID
           o    Atrovent 500mg QID
           o    Theophylline 25mls QID
           o    Frusemide 80mg mane, 40mg midday
           o    Ipratropium 500mcg bd neb/inhaled
           o    Coversyl 5mg mane
           o    Ventolin PRN
           o    Warfarin 5mg – target INR 2-3




Rural issues:

      Access: Mr. T was unable to receive the level of care and monitoring he needed in
       Stanthorpe as a result he was flown out by helicopter to Redcliffe hospital. Areas Mr. T
       needed access to which were not available included:
           o 24 hour intensive care
           o 24 hour access to pathology
           o Tracheostomy
           o Access to imaging techniques – CT scan, x-rays
           o Access to respiratory and cardiology specialists
           o Access to physicians
           o Access to echocardiogram
      As Stanthorpe is a small community, the story of Mr. T spread throughout the community
       and resulted in increasing presentations to the emergency departments of children with
       colds as parents were worried they had influenza A. Education of the community was
       needed.




Learning issues:

      This case shows the importance of close monitoring of patients. Mr. T claimed and
       appeared to be improving following admission to hospital. However, this was not the
       case and as a result of his close monitoring his respiratory distress was detected early
       and the correct measures taken to relieve it.
      In terms of AF several studies have failed to demonstrate a clear advantage of rhythm
       versus rate control (1). Whilst Mr. T remained in AF his rate was decreased from 180 to
       85 on discharge. Mr. T was also started on warfarin to prevent the sequelae of AF such
       as atrial thrombus leading to systemic embolisation.
      Although Mr. T grew positive pseudomonas aeruginosa culture in his urine, he was
       asymptomatic and it was felt that he was better of not on antibiotics. Several studies
       have shown that because of increasing antimicrobial resistance, it is important not to
       treat patients with asymptomatic bacteriuria (2).
      Finally, this case demonstrated the importance of influenza vaccine as a public health
       issue and for the prevention of influenza A.




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Public health issues:

       Transmission of viral illnesses and correct hand washing technique and tissue disposal.
       Flu vaccine – Mr. T had not had his flu shot this year
       Smoking cessation
       Antibiotics and treatment of asymptomatic UTI


Ethical issues:
    Do no harm: It was important that no harm came to Mr. T as he was being transferred.
       All lines had to be in place before transfer and the patient stabilized.
    Autonomy: Mr. T was in no position to make his own choices. He lost his free will. It
       was left to his medical team to make the choices they thought were in his best interest.
       This was particularly evident when Mr. T required defibrillation.
    Beneficence ‘Do Good’: It is important that the doctors did what they felt was in the
       best interest of the patient. In Mr. T‟s case this involved a tracheotomy and defibrillation.
    Justice: equality – Mr. T did not have access to all the medical expertise or equipment
       he needed in Stanthorpe. However, justice was achieved as he was transferred to
       Redcliffe hospital.




Bibliography


1. Randomised trial of rate control versus rhythm control in persistent atrial fibrillation: The strategies of
treatment of atrial fibrillation (STAF) study. Carlsson, J, et al. 10, s.l. : Journal of the American College of
Cardiology, 2003, Vol. 41.



2. Asymptomatic bacteriuria in adults. Colgan, R, et al. s.l. : American family physician, 2006, Vol. 74.




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Case 4: An occupational health problem

Presenting Problem:

Mr. S, a 45 year old timber cutter presented to the A&E with a deep wound to his L thigh,
following an incident with a circular saw.



History of Presenting Complaint:

      Mr. S had been sawing wood, when the circular saw slipped and went through his left
       thigh.
      There was minimal bleeding; this may possibly be due to the fact that the circular saw
       was quite hot and as such corterised the wound.
      Mr. S‟s wife is a nurse at the hospital and bandaged his wound till presentation at the
       hospital.
      Mr. S reported no loss of sensation of the lower leg, and no loss of movement



Past Medical History:

      Exercise and diet controlled hypertension



Surgical History:

      Appendectomy



No known allergies:



No current medications.



Family History:

      Asthma
      Colon cancer

Social History:

      Lives at home with his wife and 3 children 1.5 hours out of town
      Smoking: 60 pack year history



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      Alcohol: 4-6 beers/week


Examination:

      Wound measured 21cm long by 5 cm wide, and fell short of entering into muscle, major
       arteries, veins or nerves
      There were no obvious foreign bodies within the wound
      Patient appeared to be slightly pale but vital signs were normal
      HR = 84, RR = 18, T = 36.5, BP = 130/85
      There was no loss of sensation of the left lower limb


Investigations

      Nil


Provisional prognosis:

      Laceration to L thigh


Management:

      Local anesthetic – 10 ml lignocaine + adrenaline was administered at the wound site
      Wound was cleaned out using clorhexidine
      The wound was sutured, using mattress suture and 3.0 nylon thread and needle.
      The wound required 32 stitches and was covered with 3 sheets of melanin and fixamol.
      The patient was given a script for prophylactic antibiotics and discharged home with
       instructions to return in 10 days to have the stitches removed.
      The patient was told to return if the wound became red, infected, sore, and oozy or if he
       developed a temperature.


Rural issues:

      This case highlights the increased risk associated with jobs in rural Queensland. There
       are a larger proportion of manual labourers in Stanthorpe compared to Brisbane and as
       such, an increased risk of work tool related injuries.
      Access is another issue raised by this case. Mr. S lives 1.5hours out of town, and whilst
       he was fortunate to have not lacerated his femoral artery or vein, another person in his
       position who had not been so fortunate may have lost too much blood by the time help
       reached him.




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Reflections Week 1

This week, being the first week was an eye-opener. Having never spent much time in the rural
areas of QLD it was great to spend a bit of time looking around town, getting to know some of
the other students and staff and generally warming (or rather freezing as the temperature on the
first night of arrival was -2 degrees!!!) into Stanthorpe. Adjusting to the freezing cold
temperatures was somewhat of a hurdle but finding the numerous fire places, wineries and cozy
Italian restaurants made it a lot easier to tolerate the cold weather.

Medically speaking, again it was an eye opening week. It was interesting to note that there is
the full range of medical problems out in the bush that there are in cities, and then some. We
saw lacerations caused by various farming tools, injuries caused by various animals, over 10
skin lesion per day and antenatal consultations with mothers still smoking a pack a day. It was
also very interesting to note the difference in interaction between the doctor and the patient. I
mean where in Brisbane would patients show up bearing bottles of wine and chutney whilst the
doctor asked them about their kids, families and friends all by name and proceeded to
communicate via reasonably colourful language! However, the most exciting thing was finding
out that as they were so busy, with a shortage of doctors I was to be given my own room for
consultations, where I was to see patients, assess them, work out a management plan,
prescribe medications and then take them to my doctor to be signed and checked. It was scary
yet exhilarating at the same time.

The most memorable medical experience for the week was a 48 year old lady who presented
with morning sickness 5 weeks after having a tubal ligation. 10 minutes later a pregnancy test
had confirmed the impossible, she was pregnant. This was confirmed by a blood test later in the
week. It was the talk of the town and no one could comprehend how it had happened!

Another interesting case that presented was a 4 year old boy who came into the practice at 9
am with a fever, runny nose and cough. He was sent home on strict orders of rest, fluid and
panadol. The young boy returned with his mother at 4pm with a non blanching rash over his
face and body, and a fever. Whilst no signs of meningism were present the boy was rushed to
the hospital where antibiotics were administered. However, following various tests it was found
to be a viral illness.

The highlight of the social week was a visit to Anna‟s restaurant – “the multi award winning
Italian dining that doesn‟t cost the earth”. It was truly gourmet Italian food fit for royalty and was
washed down with some amazing Ballandean wine. All in all a great week.

Any thoughts about routine events/problems/encounters which happened this week:

The most disappointing part of the week was arriving with expectations of being allowed to
perform many exciting procedures, in particular skin excisions and suturing as I had heard
Stanthorpe was the capital of skin cancers! However, over 30 skin excisions later I was still not
trusted to perform these procedures. Oh well there‟s always next week.

I had also arrived in the peak of winter and hence the peak of the so called “Stanthorpe flu
epidemic” - with hundreds of patients presenting complaining of a runny nose, sore throat and
coughing up sputum which resembled Shrek. The odd patient coming in with diabetes or
hypertension was a treat! Also, as a result of the cold winter I was given the task of
administering flu injections, which whilst fun initially I think may have caused me tennis elbow!



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Reflections Week 2

Following a weekend of visiting multiple wineries, farms and restaurants heading back to the
clinic on Monday was a reminder that I wasn‟t here on holiday!

The most memorable patient/s this week presented on Monday afternoon. A man in his 40s, he
presented with stab wounds to his arm following a domestic incident! He told me of his troubled
past, issues with possible depression and anger management. By the end of the consultation he
had agreed to go see a psychologist that week and avoid his wife till after his counseling
session. The Tuesday morning, brought a loud, hung-over lady to my desk who proceeded to
inform me of the amazing relations she had had with her husband the previous night after a
shaky morning where she had stabbed him with a knife! Obviously my advice had fallen on deaf
ears! After managing to calm the patient down, it was discovered she had been diagnosed with
MS 2 years ago and since then had suffered major depression and alcohol abuse. Once again
the need for counseling was discussed and agreed upon. The couple were to be seeing the
same psychologist at different appointments as it was the only available psychologist in the
town. Not an ideal situation. To cut a long story short by the end of their sessions the
psychologist had refused to see either patient ever again citing “The patients spent the entire
time telling me what I should be telling the other person and refused to talk about themselves till
I admitted that they were in the right and the other was in the wrong”. A situation which would
never occur in a big city!

Once more the week consisted of multiple flu injections and me causing my first haematoma as
a result of an injection. Oops!

A talk given at the Town hall by professor Graham Martin on Youth Suicide and the interest
shown by the superintendent at the hospital along with the many tragic stories he told me were
the building blocks for the start of my rural health project: A brochure for medical staff at the
hospital on preventing youth suicide.

By mid week things went down hill as I awoke with a sore throat, it was as I feared; I had come
down with the Stanthorpe flu. Taking the day off I spent the entire day in bed with a fever and
vomiting everything I ate. I had a new found sympathy for my patients when I returned to work
on the Thursday!

My second interesting case for the week presented on the Friday when a guy rang up for an
urgent appointment following an accident with a vat of oil! The guy presented with his arm
bandaged, on removing the bandages I was faced with 5 blisters each the size of a large
orange. With help from the clinical nurse we bathed his wounds, applied cream and bandaged
them instructing the patient to return on the Saturday for redressing of his wounds.

Any thoughts about routine events/problems/encounters which happened this week

Week 2 and still no skin excisions or suturing undertaken!

My loving couple highlighted the shortfalls of rural towns with a small choice of psychologists!

Unfortunately, due to the nature of general practice, it has been quite difficult for me to spend a
decent amount of time with patients to get a feel for their whole case, thus making it difficult to
do case summaries on the patients.



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Reflections Week 3

This week was an eye-opener, as I became aware of the number of females under the age of
17 having children. 5 young girls presented to the clinic this week at various stages of
pregnancy, the youngest was only 14. It made me wonder whether this was a result of poor
education, pure boredom (there is nothing around to entertain teenagers as there are no
cinemas, no bowling alleys or other planned activities) or just the expected norm. The positive
side to this was the fact that antenatal classes were run at the hospital providing the young
women with the education they required whilst pregnant.

My knowledge of the stock market and property investment (previously negligible) was greatly
increased with advice and guidance provided by my preceptor. I feel I am now set to conquer
the dark unknown that is the Australian stock exchange.

However, no doubt the most memorable case this week was a young 19 year old mother of one
who presented to the GP complaining of lower back pain. Throughout the course of the
consultation it was identified that Miss A had attempted suicide on two occasions in the last
week. Furthermore, Miss A smoked numerous cones of marijuana each night to help her sleep
but never in front of her one year old child. Miss A was very keen to see a psychiatrist as she
did not want to lose her daughter. This situation made me very aware of the lack of access to
mental health assistance in Stanthorpe. It was fortunate for Miss A that a visiting psychiatrist
was present at this time. However, normally there are only psychologist in Stanthorpe with no
permanent psychiatrists. Furthermore, there is no mental health facility in which Miss A can
obtain help if she needed it.

Any thoughts about routine events/problems/encounters which happened this week:

I finally got the chance to do a punch biopsy this week! Whilst it wasn‟t a proper excision of a
lesion it was still very exciting! The procedure was completed without any complications.

The case this week also highlighted the poor access to mental health facilities for patients who
really need them.




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Journal of Achievement                                                     Maya Aoude 40119412



Reflections Week 4

This week, saw a change for me from general practice to the Stanthorpe hospital. Whilst I had
really enjoyed my GP rotation, it was great to finally get a bit more hands on work.

My nervousness at meeting new preceptors was unwarranted as the three doctors at
Stanthorpe are no doubt some of the nicest doctors I have met and made us feel part of the
team immediately!

The week consisted of ward rounds, putting cannulas in, assisting in various surgeries including;
a C-section, hernia repair and finger amputation, the insertion of a PICC line and a spider bite.
However, no doubt the highlight of the week was being involved in the vaginal delivery of a new
baby boy. The young mum was induced at 730am on the Tuesday and received half hourly
observations from myself and my fellow medical student. We all became the best of friends as
24 hours later (and no sleep) the labour was still continuing. By 10:30pm on the Monday night
her water had broken, things were now moving along…or so we thought. Countless hot
showers, ice packs, and various positions later there was still no sign of the baby. By 6am
Tuesday morning, the contractions which had been occurring every 2 minutes and lasting
1minute had slowed down to 1 every 10 minutes and the mother to be was exhausted! It was
time to call in some extra help with the on call doctor being woken up. A healthy baby boy was
eventually delivered following an episiotomy and vacuum. Whilst it has put me off having kids
for a while, it was one of the most memorable medical experiences of my university schooling
as I really felt part of the team. We followed a patient right through her labour from induction to
the final product; a beautiful baby boy.

The week was topped of by a visit to Warwick on the Thursday to see the Bourne Ultimatum.


Any thoughts about routine events/problems/encounters which happened this week:

I was asked to put a cannula into a patient the doctors said was very difficult to cannulate, so
imagine how surprised I was to get the cannula in first go! I felt on top of the world. However,
this excitement was not to last when a mere 40minutes after I had put the cannula in it fell out
whilst the patient was showering! It was a very important lesson for me in how to secure
cannulas properly. Hopefully a mistake that will never again be repeated!




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Journal of Achievement                                                     Maya Aoude 40119412



Reflections Week 5

This week was a very busy week! The normal ward rounds, venipuncture, cannulas and
outpatients were carried out. This week also saw me deliver my first and second vaginal
deliveries. The first delivery was a first time mum who following 4 hours of labour and around 40
minutes of second staging gave birth to a healthy baby girl. The second case was a mum giving
birth to her 4th baby and what a difference that made! Following 2 hours of labour and around 20
minutes of second staging the health baby boy pretty much delivered himself! It was an amazing
experience, yet at the same time nerve racking as I waited with baited breath for the baby to
start crying.

The end of the week, Friday afternoon at 5:30pm I was called into the emergency department
by the doctor to see a man who had gone through his thigh with a circular saw whilst chopping
wood. Luckily for the gentlemen he had missed all the important structures of the thigh. I was
given the job of suturing him back together. 2 hours later and around 30 stitches the wound was
cleaned, sutured and dressed ready to go.

Unfortunately, the week was slightly stressful for me as during immunizations at the local
school, one of the nurses accidently stabbed me with a needle after the immunization had been
given. This resulted in both me and the patient needing to get blood tests, the results of which
will not be available till Wednesday of week 5.

This week also saw the final week for one of our preceptors. This called for lunch celebrations at
the local pizza and pasta place.


Any thoughts about routine events/problems/encounters which happened this week:

Whilst, I had previously sutured patients they had never been lesions as large as the one I was
asked to suture this week. As a result of the length and width of the wound the doctor requested
mattress stitches. Whilst technically I was able to do this, I was quite exasperated by how slow I
was compared to doctors I had seen do them in the past. I guess it is just something that comes
with time and experience.




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Journal of Achievement                                                     Maya Aoude 40119412



Reflections Week 6

The final week at Stanthorpe hospital was a hectic one! In addition to the normal every day work
there was also assessment and last week socializing to be done.

The most memorable case this week was two adorable 6 year old twins who presented to the
emergency department following the consumption of several wisteria seeds each. Both girls had
been vomiting for the last 2 hours and had started to bring up blood. After quickly examining the
girls who both claimed to be feeling better after their vomits a call was placed to the poisons
hotline. Fortunately, for the family the seeds did not have any long term or serious side effects.
However, they did cause vomiting and diarrhea for a period of 48 hours. The girls were admitted
into hospital overnight for observations and for fluid replacement.

This week also presented the headache of trying to print my rural project brochure. Getting it to
fold exactly with the right print margins was almost impossible! In the end I had to settle for
almost but not quite perfect.

Our final night here was celebrated with a dinner at one of the doctors houses and it was a great
experience!

Overall, the rural experience has been priceless.

Any thoughts about routine events/problems/encounters which happened this week:

Apart from the brochure printing this week seemed to be problem free! The routine procedures I
have obtained experience in throughout my rural rotation are:
    IM immunizations
    SC injections
    Cannula insertion and IV line set up
    Wound dressing including burns
    Suturing of wounds
    Vaginal deliveries
    Assisting in various surgeries, including: caesarian sections and hernia repairs
    Ward testing urine
    Finger prick BSL
    ECGs
    ISTAT




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Journal of Achievement                                                            Maya Aoude 40119412



Section C: Discuss (4) situations or cases relevant to each of the four Domains of
Learning

Biomedical Science: The Effect of Phenytoin on the Oral Contraceptive Pill

Mrs. T, a 34 year old female presented to the A&E department following a grand mal seizure on
a 14 year background of epilepsy. Following treatment and rest Mrs. T enquired about the
effectiveness of the oral contraceptive pill when taken in conjunction with phenytoin, as she had
recently read an article on it. Phenytoin is an anticonvulsant drugs which inhibits the spread of
seizure activity within the motor cortex, possibly by promoting sodium efflux from neurons,
stabilizing the threshold against hyperexcitability. Phenytoin has been shown to be associated
with higher failure rates of oral contraceptive pills. This is believed to be due to the breakdown
and binding of reproductive steroids by phenytoin. The exact process by which this occurs is
unknown (1). Furthermore, the use of phenytoin in conjunction with the OCP has been
associated with increased seizure frequency. Phenytoin and reproductive steroids are
metabolized by the same hepatic enzymes. As the OCP decreases the levels of some of these
hormones, there is an increased metabolism of phenytoin, resulting in lower serum levels (2). In
addition to this, phenytoin is largely inactivated by hepatic glucuronidation, a process that is
induced by OCP. It is important to look out for menstrual disturbances such as break-through
bleeding, amenorrhea and irregular menses which occur 4 times more frequently than
pregnancies (3).

The failure of OCP in conjunction with the use of phenytoin is a significant issue as phenytoin is
associated with a higher incidence of birth defects in children such as cleft palate and heart
malformations. More importantly phenytoin has recently been linked with fetal hydantoin
syndrome (prenatal growth deficiency, microcephaly and mental deficiency) (4).

Second generation anticonvulsants including lamotrigine and gabapnetin have not been found
to have any significant impact on the efficacy of the OCP. Alternatively patients should be made
aware that they need to take additional precautions or alternative contraceptive measures.

Therefore, in answer to Mrs. T‟s question, Phenytoin has the potential to decrease the efficacy
of the OCP. At the same time, the OCP decreased the effectiveness of phenytoin leading to
increased seizure frequency.


Bibliography

1. Ineractions between antiepileptic drugs and hormonal contraception. Crawford, P. s.l. : CNS drugs,
2002, Vol. 16.

2. Ovarian hormones, anticonvulsant drugs and seizures during the menstrual cycle in women with
epilepsy. Roscizewska, D, Buntner, B and Gus, I. s.l. : J Neurol Neurosurg Psychiatry, 1986, Vol. 49.

3. Pharmacokinetic drug interactions between oral contraceptives and second-generation
anticonvulsants. Wilbur, K and Ensom, M. 4, s.l. : Clinical Pharmacokinetics, 2000, Vol. 38.

4. Long, P. Mental Health - Phenytoin. Mental Health. [Online] 2005. [Cited: September 2, 2007.]
www.mentalhealth.com/drug/p30-d05.html.



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Journal of Achievement                                                                Maya Aoude 40119412



Population Health: The use of Antibiotics for Viral Illnesses, Patient Education and Super
bugs

With widespread influenza-like activity in Stanthorpe, one thing which really stood out to me was
the regular prescription of antibiotics when there was no obvious need for them. Antibiotics
resistance is a critical public health issue with bacteria becoming stronger and less responsive
to antibiotic treatment over the last decade. Antibiotics are frequently prescribed for acute
respiratory infections despite evidence showing that they are ineffective. A decrease in
unnecessary antibiotic use can significantly decrease antibiotic resistance among community
pathogens (1).

Antibiotic prescribing is heavily influenced by patients‟ expectations and demands for antibiotic
treatment. As a result education of patients and the public is an important line of attack for
reducing the use of antibiotics. Research has shown that many people do not understand that
antibiotics kill bacteria only; not viruses. In a study by Avery et al 55% of people believed that
antibiotics were beneficial for viral respiratory illnesses such as the common cold and flu. The
study also found that previous use of antibiotics was associated with believing that antibiotics
are effective for the common cold or flu (2). This highlights that there is a significant need to
educate patients and perhaps some doctors on the effectiveness of antibiotics for the treatment
of colds, flu‟s or other viral illness.

Education of patients and the public has been found to reduce number of visits to the doctor for
colds, as well as reducing antibiotic prescriptions. It has further been shown that despite the
belief held by doctors that patients expect antibiotics, patients are satisfied when they
understand the choices doctors make in not prescribing them antibiotics (2). The public needs to
be made aware that antibiotics do not make patients with viral infections feel any better, recover
faster or protect others from getting sick. A message needs to be sent out to the public that viral
symptoms (Fever, headache, tiredness, dry cough, sore throat, nasal congestion and body
aches) can not be treated by antibiotics, but rather the following approach should be taken:
     Increased fluid intake
     Rest
     Use of a cool mist vaporizer or saline nasal spray to relive congestion
     Sooth sore throat with ice chips, sore throat spray or lozenges
     Over the counter medication such as cold and flu tablets to relive symptoms.

It is this treatment we need to educate patients about if we hope to prevent further antibiotic
resistance. Whilst this message has been passed on by the Australian government over the last
couple of years with the use of TV Advertisements and pamphlets, there is perhaps a need for
further education within the rural parts of Queensland if we are to prevent the creation of further
super bugs.



Bibliography
1. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group
A streptococci in Finland. Seppala, H, Klaukka, T and Vuopio-Varkila, I. 337, s.l. : N Engl J Med, 1998.

2. Public beliefs and use of antibiotics for acute respiratory illness. Wilson, A, et al. Colorado : Journal of
General Internal Medicine, 1999, Vol. 14.



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Journal of Achievement                                                         Maya Aoude 40119412



Clinical Science: Prophylactic systemic antibiotics for simple lacerations

Mr. A, presented to A&E following a laceration to his hand by a knife. Following his presentation
there was debate by the doctors as to whether prophylactic antibiotics should be given. It raised
the question: Do systemic antibiotics prevent infection of simple wounds sutured in the
emergency department? In order to justify their use the benefits of prophylactic antibiotics
should outweigh the risks. Risks associated with antibiotic use include but are not limited to;
nausea, vomiting, diarrhea, development of resistance, alteration of the normal bacterial flora,
allergies, related costs, and fear of litigation. Alternatively, if antibiotics are not used when
needed, infection of the hand wound may result in cosmetically unappealing scars or in the
worse case scenario, a need to remove the infected area.

A meta-analysis conducted by Zehtabehi showed that whilst systemic antibiotics might benefit
certain immunocompromised populations such as diabetic patients, AIDS patients,
chemotherapy patients or those on chronic steroids and animal bite wounds they do not confer
any benefit to patients with simple lacerations (1) (2). In a trial looking at 778 simple hand
lacerations no statistically or clinically significant benefit to antibiotic use was demonstrated.
These results held regardless of the choice or route of systemic antibiotic administration.
However, decreased rates of wound infection were reported in sutured lacerations treated with
topical antibiotics such as Neosporin. Well-vascularised areas of the body such as the scalp and
face were found to be less likely to become infected (1). More importantly, it is important that
the use of routine antibiotics does not replace the importance of standard wound care such as
aggressive irrigation and debridement. Nothing should supersede thorough wound care and
closure techniques.

In conclusion there is no persuasive inclination toward either benefit or harm from administration
of antibiotics for uncomplicated hand lacerations. Clinical judgment based on the individual case
looking at the clinical circumstance (i.e. relevant medical conditions or method of injury) should
be exercised.



Bibliography

1. The Role of Antibiotic Prophylaxis for Prevention of Infection in Patients With Simple Hand
Lacerations. Zehtabchi, Shahriar. New York : Emergency Medicine Journal, 2007, Vol. 24.
2. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomised studies. Cummings,
P and Del Beccaro, MA. s.l. : Am J Emerg Med, 1995, Vol. 13.



Ethics and Professional Practice: The case of Mrs. V

Mrs. V, presented to her general practitioner complaining of mood swings, vomiting and feeling
nauseated of a morning and tender breasts. Several tests later, it was determined Mrs. V was
pregnant. A very unexpected outcome for all parties as Mrs. V had undergone a hysterectomy in
Brisbane 8 weeks earlier. Mrs. V already had 5 children under the age of 8 and did not feel she
could provide for another child emotionally or financially and requested an abortion. This case
raises the issue of Negligence as Mrs. V has not been told there was a chance the procedure
may not work and the ethical issue of abortion.



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Journal of Achievement                                                        Maya Aoude 40119412




In order to claim negligence one must prove that:

      A duty of care existed
      There was a breach in the standard of care
      Damage occurred
      Causation –The breach caused the damage

The Civil Liability Act 2003, states that adequate disclosure requires a doctor disclose
information that a reasonable person in the patients position would require to make an informed
decision. I think in this situation it would be accurate to assume that Mrs. V would consider the
possibility that she may fall pregnant after the surgery to be a significant risk. Mrs. V, states that
had she known the operation was not always a success she would not have gone ahead with it.
However, under the Civil Liability Act, statements from the patient concerning what they would
have done had they been adequately informed are excluded.

Mrs. V‟s surgeon had a duty of care towards her, which he breached resulting in damage. Is this
then a case of negligence?

The abortion debate has been around for centuries. What issue most determines the rights and
wrongs of abortion? Is it the women‟s right to control her own body or the fetus‟s right to life?
There is no simple answer to this. Mrs. V was unable to obtain an abortion in Stanthorpe as the
acting doctors within the hospital had strong religious views against this. She was forced to go
elsewhere for her abortion even though she had taken all precautions to avoid falling pregnant.

Abortion is a criminal offence in all states except Western Australia and is prosecuted under
criminal law as opposed to civil law. However, possible statutory protection is offered by s282
against criminal proceedings in regards to abortions. “A person is not criminally responsible for
performing in good faith and with reasonable care and skill a surgical operation upon any
person for his benefit, or upon an unborn child for the preservation of the mother’s life, if the
performance of the operation is reasonable, having regard to the patient’s state at the time and
to all circumstances of the case.” Does the fact that Mrs. V, took all possible means to avoid
pregnancy as she knew she was not in the position emotionally or financial to bring another
child into the world provide her protection under s282?


Bibliography:
    All notes taken from lectures given throughout first and second year medicine




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Journal of Achievement                                                    Maya Aoude 40119412



Section D: Procedures I have learnt/practiced

      IM immunizations
      SC injections
      Cannula insertion and IV line set up
      Wound dressing including burns
      Suturing of wounds
      Vaginal deliveries
      Assisting in various surgeries, including: caesarian sections and hernia repairs
      Ward testing urine
      Finger prick BSL
      ECGs
      ISTAT




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