Cultural Competence and Indigenous Health — DCE Clinical Case

Station scenario

Setting. General medical ward of a metropolitan teaching hospital, 800 km from the patient's remote community. [1]

Patient. Mrs K is a 48-year-old Aboriginal woman from a remote community in the Northern Territory, admitted overnight with a 5-day history of progressive breathlessness, orthopnoea and bilateral leg swelling. [1]

Admission data.

• Blood pressure 104/68, heart rate 112 and irregularly irregular (atrial fibrillation), respiratory rate 24, oxygen saturation 90 per cent on room air
• Bilateral basal crackles, raised JVP, bipedal oedema
• Echocardiogram: severe rheumatic mitral stenosis (valve area 0.9 cm2), moderate mitral regurgitation, mild aortic regurgitation, left atrial dilatation, no left atrial thrombus
• HbA1c 84 mmol/mol, eGFR 38, ACR 65 mg/mmol, total cholesterol 5.8
• INR 1.1 (not anticoagulated)
• Chronic right ear discharge on otoscopy with central tympanic membrane perforation
• History of ARF at age 12, on secondary prophylaxis (benzathine penicillin G every 28 days) but has missed 4 of last 6 injections
• 800 km from home, 14-year-old son is her primary carer, no Aboriginal Health Worker has been involved
• Nursing notes describe her as 'non-compliant'
• Known depression, not currently engaged with mental health services [1]

Task. The candidate has 25 minutes to assess the patient, take the history, consider the investigations, formulate a prioritised problem list and an integrated management plan, and be prepared to present to the examiner and answer probing questions. [1]