Chronic Disease Management Flashcards
What are first line management options for mild to moderate acne?
Topical adapalene (retinoid) with topical benzoyl peroxide
Topical tretinoin with topical clindamycin
Topical benzoyl peroxide with topical clindamycin
(if signs of pustules may consider ABx preparation more useful)
How do you advise a patient to use topical retinoids or benzolyl peroxide?
Try on a small area of skin first for an hour. Warn the patient about skin irritation. Slowly increase to using every night and wash face in the morning. Ensure it is used on normal skin and not just on spots.
(Roughly 25% benefit every 3 months, most full 12 months to see benefit)
What are 3 common side effects of topical retinoids?
Erythema
Dryness
Stinging/ itching
Peeling
What are the two most common side effects of topical benzoyl peroxide?
Erythema
Dryness
If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is mild/ moderate, what is your next step?
Trial different first line option
Topical:
Retinoid + BP
BP + ABx
Retinoid + ABx
If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is mod/severe, what is your next step?
If first treatment:
Didn’t include oral ABx - Prescribe oral abx
Did include oral ABx -
Refer to specialist
A 16 year old with mild/ moderate acne presents with a marked improvement following initial 3 month treatment with tretinoin + clindamycin. What options do you have for next step?
Stop (maintenance not always necessary)
Maintenance with topical adapalene and topical benzoyl peroxide
Maintenance with monotherapy (adapalene 0.1% or benzoyl peroxide 5%)
What is the definition of CKD?
Decreased kidney function (eGFR <60) for 3 months or more
AND/OR
Persistent proteinuria (ACR >3) for 3 months or more
What is the definition of accelerated progression of CKD?
Accelerated progression of CKD is defined as a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months, or a sustained decrease in GFR of 15 in 12 months
How is CKD classified?
Stage 1: Normal eGFR >90
Stage 2: Mild impairment eGFR 60-89 with other evidence of damage
Stage 3a: eGFR 45-59
Stage 3b: eGFR 30-44
Stage 4: eGFR 15-29
Stage 5: eGFR <15 (established renal failure)
How often should eGFR and urinary ACR be performed in patients with CKD?
Once stage 3 at least annually, depending on stage of eGFR and also ACR. Online table gives details but once- four times yearly
How should you manage a newly diagnosed CKD3? (4 points)
1) Meds review (NSAID, diuretic etc. which may harm)
2) Manage BP (<140/90 or <130/85 if diabetic)
3) Add ACEI (if diabetes/ HTN)
4) Statin and cardiovascular RF management (lifestyle etc)
5) Consider gliflozin (if diabetes/ ACR over 22, eGFR 25-75 and already on high dose ACEI or ARB)
You are seeing a 49 year old gentleman with T2DM, HTN and newly diagnosed CKD3 on Ramipril, Atorvastatin and Metformin. HbA1c is 53, what additional medicine should he be on?
SGLT2 Inhibitor (Glifozin, i.e. Dapagliflozin)
All patients with T2DM and CKD
When should you refer a patient with CKD for secondary care support (4)?
1) eGFR under 30
2) ACR > 70 (unless known diabetes) or ACR > 30 with haematuria
3) 25% decrease in eGFR or drop 15 within 12 months
4) Poorly controlled HTN despite 4x antihypertensive
Your patient has a TSH of 30.5 (0.35-0.94) and a T4 of 9.1 (9-19). They are symptomatic and this is persistent. How do you initiate therapy and when do you adjust if needed?
Hypothyrodism> Initiate levothyroxine
- Adults under 50yrs - Start 50mcg OD, adjust in steps 25-50mcg every 4 weeks (usually 100-200mcg daily)
- Adults over 50yrs - Start 25mcg OD, adjust in steps of 25mcg every 4 weeks )usually 50-200mg OD)
How should a patient with hypothyroidism be advised to take their levothyroxine?
Empty stomach
First thing in a morning before food or other medication
When going through labs a patient is found to have a TSH of 30.5 (0.35-0.94) and a T4 of 9.1 (9-19). They are asymptomatic. What is the next step?
Subclinical hypothyroid
- Referral if (goitre, pregnant/ planning pregnancy, drugs such as lithium or amiodarone) or if considered RE malignancy (neck mass)
- Consider treatment with levothyroxine if TSH >10 and T4 normal range on 2 occasions 3 months apart
When going through labs one asymptomatic patient has a TSH reading of 0.08, you note this was done 3 months ago and was 0.04 at the time. What is the next step?
Subclinical hyperthyroidism
Arrange to assess, referral to endocrine if:
- Two TSH levels <0.1 3 months apart
AND
- Evidence thyroid disease (goitre, TSH-receptor antibodies or symptoms thyrotoxicosis)
Consider urgent 2ww if goitre, nodule or structural change in thyroid gland (TFT’s usually normal in thyroid cancer)
What blood tests should you monitor for a patient with beta thalassemia and what results would you expect?
FBC - Ensure no haemolytic anaemia
- Expect low MCV, with microcystic, hypochromic anaemia
- Aim to keep Hb above 95
Ferritin - Prone to iron overload, only replace iron if proven iron deficiency
LFT’s- Bilirubin to check for haemolysis
HbA2 > 3.5% is diagnostic of thalassemia
Name 3 presenting features that would make you consider PCOS?
Infertility, oligomenorrhoea or amenorrhoea
- In adolescent, consider Ix after 1 year of irregular cycles since menarche
Hirsutism or acne
Family history PCOS
Obesity
Acanthosis nigrans
What is the diagnostic criteria for PCOS?
Need two out of three:
1) Infrequent or no ovulation
2) Clinical or biochemical signs hyderandrogenism (hirsuitism, acne, elevated total or free testosterone)
3) Polycystic ovaries on USS
(12 or more follicules or volume over 10cm3 in one or both ovaries)
What key investigations should be performed when considering PCOS as a diagnosis? (3)
USS
Total testosterone
Sex hormone binding globulin (SHBG)
FSH/ LH/ TFT’s and prolactin - rule out other causes oligo or amenorrhoea
You have just diagnosed your patient with PCOS, what should be done with regard to counselling on long complications? (4)
1) Inform increased risk T2DM and CVD
2) Offer advice on weight loss and exercise
3) Offer screening for T2DM (HbA1c) and CVD risk
4) Ask about snoring/ daytime somnolence - if relevant refer to OSA ix and tx
How do you manage oligo or ammenorhoea in a newly diagnosed PCOS patient?
First need TVUS to assess endometrium thickness, if no hyperplasia, options include:
1) Cyclical progesterogen
2) Low dose COCP
3) Mirena IUS
Advise weight loss may help menstrual irregularity
A patient has a new beta thalassemia trait diagnosis - what action do you need to advise?
Inform when wishing to conceive will need to test baby
No actions needed til then
A patient presents with symptomatic hyperthyroidism, confirmed on bloods. They have some eye signs and you suspect graves syndrome - what blood test do you perform?
TSH receptor antibodies
- Graves = 80% of hyperthyroidism (10:1 female), most common 30-50
- Commonly with other autoimmune conditions
What is the role of TPO antibodies in diagnosing thyroid disease?
If high TSH (suspected hypothyroid) TPO helps establish the cause:
- Raised TPO antibodies = autoimmune cause (90%) i.e. Hashimoto’s
- Normal TPO antibodies = More like transient and not autoimmune cause
Name three complications of hypothyroidism?
Dyslipidaemia, metabolic syndrome, coronary heart disease, stroke, heart failure
Neurological and cognitive impairments
Adverse maternal and fetal outcomes in pregnancy.
Name three possible signs or symptoms of graves orbitopathy?
Excessive eye watering
Double vision, change in visual acuity or color vision,
Eyelid retraction or lid lag
Proptosis
A young female patient who presented to you with sweating and anxiety is shown to have low TSH and raised T4. You diagnose hyperthyroidism. What should be done regarding starting medication?
Refer to specialist to initiate carbimazole/ propylthiouracil
Can offer beta blocker to help with symptoms
A patient has subclinical hyperthyroidism. What is the criteria for referral to endocrinology?
Two TSH readings <0.1 - 3 months apart + evidence of thyroid disease (symptoms, goitre etc)
A 32 year old woman with subclinical hyperthyroidism presents as she is planning a pregnancy. What is the referral timeline?
Urgent referral for all patients with any hyper/hypothyroid who are planning pregnancy or pregnant to endocrinology
A 44year old has a routine health check. TSH is 7.8 (0.4-4) and T4 is 14 (9-20).
How is she best managed?
Repeat TFT’s in 3-6 months
British Thyroid Association suggest treatment when the TSH is greater than 10 mU/l.
If asymptomatic observe and rpt in 3-6 months time
How should vaping be considered when looking at UKMEC for contraception?
FSRH says treat vaping the same as smoking when assessing UKMEC risk
What are the simon Broome criteria?
For familial hypercholesterolaemia
Total cholesterol > 7.5 or LDL > 4.9
AND
1) Tend xandthoma or confirmed mutation in them or relative = Definite
OR
2) Premature CHD or high cholesterol in relative = Possible
- Refer both to lipid clinic
Name 5 possible eczema triggers?
Irritants (Clothes, allergens, soaps)
Inhalents (pollen, pets etc)
Hormones
Climate (cold usually worse)
Stress/ illness
Diet (milk, egg, wheat, penut)
What is the common genetic pattern of familial hypercholesterolemia?
Most people with FH have inherited a defective gene for the condition from one parent only (heterozygous FH). Rarely, an affected person will inherit a genetic defect from both parents (homozygous FH).
