Case 59: Rosie Inkamala

INSTRUCTIONS FOR THE DOCTOR

This is a long case.

Please take a focused history from Rosie. Outline to Rosie your differential diagnosis and negotiate a management plan with her.

The following information is on her summary sheet:

• Past medical history

• Rheumatic fever aged 15

• Atrial fibrillation (AF)

• Alcoholic hepatitis

• Hypercholesterolaemia

• Medication

• Atorvastatin 10 mg od

• Aspirin 100 mg od

• Digoxin 0.625 mg od

• Ramipril 10 mg od

• Etonogestrel intrauterine implant six months ago (Mirena)

• Allergies

• Nil known

• Immunisations

• Up-to-date

• Cervical screening test

• Normal this year

• Social history

• High alcohol use

• Chews tobacco.

INSTRUCTIONS FOR THE PATIENT, ROSIE INKAMALA

You are a 36-year-old Indigenous woman. Two days ago, on the weekend, you could not move your right arm or leg for about half an hour. You thought that you were having a stroke and were relieved when the movement came back. Today you have decided to come to see the GP for a check-up, now that the clinic is open. You drink heavily whenever you can afford it, which works out at more than 10 standard drinks three to four days a week. When you drink you tend to forget your medications, which are in a Webster pack.

You live with extended family and your two children and feel safe at home.

You are very scared of having a stroke after seeing your aunt suffer from a big stroke last year; you are motivated to do what the doctor thinks you should do. If they suggest stopping drinking, tell them you will need help to stop.

You are fluent in four Aboriginal languages, but your English is limited.

Clinical examination findings

BP 124/82 mmHg

No evidence of cardiac failure

Rate-controlled atrial fibrillation (AF)

No residual neurological findings.

The following information is on your medical record:

• Past medical history

• Rheumatic fever aged 15

• Atrial fibrillation (AF)

• Alcoholic hepatitis

• Hypercholesterolaemia

• Medication

• Atorvastatin 10 mg od

• Aspirin 100 mg od

• Digoxin 0.625 mg od

• Ramipril 10 mg od

• Etonogestrel intrauterine implant six months ago (Mirena)

• Allergies

• Nil known

• Immunisations

• Up-to-date

• Cervical screening test

• Normal this year

• Social history

• High alcohol use

• Chews tobacco.

SUGGESTED APPROACH TO THE CASE

Request the assistance of an interpreter

Establish rapport

Open-ended ...