This second edition maintains the role-play style of the successful first edition, where students use a variety of case studies to practise their clinical examination skills. Each case has been revised, and 25 new cases have been added. All cases include instructions for both the exam candidate and the patient, with suggested approaches as well as up-to-date references and further readings. The format is ideal for students, international medical graduates and general practice training programs.

1. 1
Section 1 Adolescent health
Case 1 Erin Campbell
Instructions for the doctor
This is a short case.
Please take a history from Erin, examine her face only, then outline the
most likely diagnosis and negotiate a management plan with her.
Scenario
Erin Campbell is a 14-year-old girl who presents to you with moderate
facial acne. Her mum has come with her to the surgery but lets Erin
see you on her own.
The following information is on her summary sheet:
Past medical history
Nil significant
Medication
Nil
Allergies
Nil
Immunisations
Up to date
Social history
Lives with parents.

2. SECTION 1 ADOLESCENT HEALTH
2
Instructions for the patient Erin Campbell
You are 14 years old and attend the local high school. Your zits dominate
your life. Each morning your mum shouts at you to get dressed and ready
for school while you stare at your zits in the mirror. You are convinced that
you will never have a boyfriend like all your other friends. You used to take
comfort in eating chocolate and cheese but have stopped since a friend said
that was causing your zits.
You are embarrassed to be going to see the GP and hope the doctor will
be kind.
The following information is on your summary sheet:
Past medical history
Nil significant
Medication
Nil
Allergies
Nil
Immunisations
Up to date
Social history
Lives with Mum.

3. ERIN CAMPBELL CASE 1
3
Suggested approach to the case
Establish rapport with Erin
Open-ended questions to explore Erin’s concerns and expectations about
her acne.
Specific questions
Duration of acne
Location of acne
Impact of acne on social life and relationships
What has she tried so far as treatment?
What does she think causes the acne?
General health, e.g. are her periods regular?
Request permission to examine.
Examination
Examine the face
—confirm acne
—describe signs: comedones, pustules, erythema or scarring.
Management
Explain medical understanding of cause of acne without using jargon
Reassure that diet is not proven to change acne
Reassure that acne can be controlled, should not stop her socialising
Advise against picking or squeezing
Offer treatment depending on what Erin has already tried
Advise regular washing with soap
Avoid oily or greasy skin preparations
Treatment takes 4–8 weeks to be effective, can combine topical and oral
treatments
Reduce excess cells (hyperkeratinisation)1
Topical retinoids, azelaic acid

4. SECTION 1 ADOLESCENT HEALTH
4
Reduce bacteria (propioniobacterium acnes)
Benzoyl peroxide, strength according to skin type
Topical antibiotics (combine with Benzoyl peroxide to reduce antibiotic
resistance)2
Oral antibiotics—tetracyclines not recommended until bone and teeth
development complete
Rebalance hormones (reduce androgen excess)
Oral contraceptives containing an anti-androgen, such as cyproterone with
ethinyloestradiol
Reduce sebum hypersecretion
Oral isotretinoin—high risk of teratogenicity
Arrange follow-up.
Case commentary
Adolescent acne is a common problem and can lead to physical and
psychological scarring.3
Refer to Figure 1, centre insert page A.4
Myths
about its cause abound but the doctor can reassure Erin that the acne is
not her fault and is not related to junk food. However, there are other
good reasons to encourage a healthy diet.
Typically many treatments will have been tried at home prior to
consulting a GP. It is important to find out what Erin has tried so you
are offering something new rather than a treatment that has already been
tried and failed.
For some teenagers, the hidden agenda of an acne presentation is a
request for contraception. This requires sensitive exploration. A phrase
that I find useful is: ‘Some people who come to see me know that the
contraceptive pill helps with their skin; is this the case with you?’ The
question about Erin’s periods is to assess the likelihood of polycystic
ovarian syndrome.
Common pitfalls
Teenagers determine the severity and impact of their acne, not doctors.
This case tests the doctor’s ability to practise in a patient-centred
framework. Low marks will be given to doctors who dismiss Erin as
having a few pimples which are insignificant and which she should learn
to live with.

5. ERIN CAMPBELL CASE 1
5
References
1. Goodman, G 2006, ‘Managing acne vulgaris effectively’, Australian Family
Physician, vol. 35, no. 9, pp. 705–8.
2. Laubscher, T, Regier, L & Jin, M et al. 2009, ‘Taking the stress out of acne
management’, Canadian Family Physician, vol. 55, no. 3, pp. 266–9.
3. Goodman, G 2006, ‘Acne and acne scarring: the case for active and early
intervention’, Australian Family Physician, vol. 35, no. 7, pp. 503–4.
4. Usatine, RP, Smith, MA & Mayeavz Jr, EJ 2009. The Color Atlas of Family
Medicine, McGraw-Hill, New York, NY, p. 439.