Stations

You are the dermatology registrar in a regional New South Wales hospital. Your Thursday clinic is already running forty minutes late when the last referral of the day arrives: a 15-year-old girl brought over from the youth justice centre twenty minutes away, accompanied by two youth justice officers. She is wearing a hoodie with the sleeves pulled down over her wrists, and you can see the edge of a handcuff. The officers tell you they have been instructed to remain in the room, and that transport has to leave by four. The referral is two lines from the centre's clinic nurse: "Eczema, worse. Please review." You piece the rest together from the record. She has had atopic dermatitis since infancy. Eighteen months ago a paediatric dermatologist at the metropolitan children's hospital started her on fortnightly dupilumab, after methotrexate and then a course of ciclosporin had failed; her EASI fell from 28 to 4 and the clinic letters describe her as transformed. Her last injection was nineteen weeks ago. She has been in custody for eleven. The centre's medication chart lists paracetamol as required and the combined oral contraceptive pill; there is no emollient, no topical corticosteroid and no antihistamine on it. A GP visits the centre fortnightly and a nurse is on site on weekdays. Her file records that she identifies as Aboriginal, that her grandmother is her legal guardian, and that she is due for release in eleven days. On examination there is widespread lichenified, excoriated eczema across her flexures, neck and hands, weeping honey-coloured crust in both antecubital fossae, and post-inflammatory pigment change over her cheeks. She has scratched her forearms to bleeding. She says she sleeps about three hours a night. There is a 4 mm evenly pigmented macule on her upper back that she says has been there as long as she can remember. She scratches continuously while you talk, answers most questions with "dunno", and will not meet your eye. Asked what bothers her most, she says quietly that she has stopped going to the education unit because of how her face looks, then adds: "don't write that down, they read it." You telephone the centre's clinic nurse. She mentions in passing that the centre does not stock topical corticosteroids and that emollient has to be individually approved for each young person; that nothing is kept in the young people's rooms, so anything topical is applied at the morning medication round; and that two others on the same unit have been treated for itchy rashes in the past month. As you finish, one of the officers asks whether you will write a letter for her court date next month. The panel has only one question for you. Tell us how you would approach this scenario, focusing on strategies for managing socially disadvantaged children in the corrections facility.

Vulnerable populations · Health Advocate · Culturally Responsive Practitioner · Communicator · Leader

You are the dermatology registrar in a general dermatology clinic at a metropolitan teaching hospital in New South Wales. It is the Thursday afternoon systemic therapy review clinic. Your consultant is running the adjoining room and has asked you to see the next four patients and to bring anything you are unsure about through to her. A final-year medical student is sitting in with you for the afternoon. The patient is a 22-year-old woman in the third year of a nursing degree, referred by her GP five months ago. Since the age of sixteen she has developed multiple firm, skin-coloured dermal cysts across the chest, upper arms, axillae and thighs - more than forty at the last count. Over the past two years around a dozen have become inflamed, discharged an oily fluid and healed with depressed scars. An excisional biopsy showed a cyst wall of flattened stratified squamous epithelium with no granular layer, an undulating eosinophilic cuticle, and sebaceous lobules within the wall, confirming steatocystoma multiplex. Her father and a paternal aunt have the same lumps. Her nails, teeth and palms are normal. She had three months of doxycycline 100 mg daily with no change, and two lesions incised and drained in ED last summer. Six weeks ago she was commenced on isotretinoin 20 mg daily; she weighed 61 kg. Steatocystoma is not a PBS indication, so the script is private and costs her about $70 a month. She was counselled about teratogenicity, asked to use two forms of contraception and to attend for monthly pregnancy testing. Baseline bloods were normal. At her four-week telephone review with the clinic nurse she said the tablets had made no difference and asked whether there was any point continuing. She has rescheduled today's appointment twice by email. Today's file contains a nursing note from this afternoon recording her weight as 55 kg; bloods taken three days ago showing an ALT of 74 U/L against a baseline of 21, fasting triglycerides of 3.2 mmol/L against a baseline of 1.1, and a normal full blood count and renal function; and a negative pregnancy test this morning. Her medication list still carries fluoxetine 20 mg daily, annotated ‘ceased February at patient's request’ after two years on it, alongside the isotretinoin and a combined oral contraceptive pill. The dispensing history from her pharmacy shows the isotretinoin collected on time both months and the contraceptive pill last dispensed in March. The clinic's isotretinoin review sheet, which you complete at every visit, has fields for cheilitis, xerosis, epistaxis, myalgia, headache, visual disturbance, pregnancy test, ALT, fasting lipids and the number of inflamed cysts. The hospital pharmacist has left a note on the front of the file asking whether the dose should be increased to 40 mg given the lack of response. Her mother telephoned the clinic yesterday, said she was worried about her daughter, and asked to be rung back after today's appointment. She has come alone and is in the waiting room. Your consultant puts her head round the door, says she has seen the pharmacist's note, and asks you what you are going to cover in the ten minutes you have, and in what order.

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You are the dermatology registrar in a Sydney pigmented lesion clinic. Six months ago your term supervisor, who assesses you, imaged a macule on your patient's back and booked a three-month recall that was never sent. His GP has since excised a melanoma with nodal spread. With the patient beside him, today's consultant says twice that it should have been picked up earlier, then does not answer when he asks whether this was a mistake.

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