Chronic Disease Management

Question 1

What are first line management options for mild to moderate acne?

Answer 1

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)

Question 2

How do you advise a patient to use topical retinoids or benzolyl peroxide?

Answer 2

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)

Question 3

What are 3 common side effects of topical retinoids?

Answer 3

Erythema
Dryness
Stinging/ itching
Peeling

Question 4

What are the two most common side effects of topical benzoyl peroxide?

Answer 4

Erythema
Dryness

Question 5

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?

Answer 5

Trial different first line option

Topical:
Retinoid + BP
BP + ABx
Retinoid + ABx

Question 6

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?

Answer 6

If first treatment:

Didn’t include oral ABx - Prescribe oral abx

Did include oral ABx -
Refer to specialist

Question 7

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?

Answer 7

Stop (maintenance not always necessary)

Maintenance with topical adapalene and topical benzoyl peroxide

Maintenance with monotherapy (adapalene 0.1% or benzoyl peroxide 5%)

Question 8

What is the definition of CKD?

Answer 8

Decreased kidney function (eGFR <60) for 3 months or more
AND/OR
Persistent proteinuria (ACR >3) for 3 months or more

Question 9

What is the definition of accelerated progression of CKD?

Answer 9

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

Question 10

How is CKD classified?

Answer 10

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)

Question 11

How often should eGFR and urinary ACR be performed in patients with CKD?

Answer 11

Once stage 3 at least annually, depending on stage of eGFR and also ACR. Online table gives details but once- four times yearly

Question 12

How should you manage a newly diagnosed CKD3? (4 points)

Answer 12

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)

Question 13

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?

Answer 13

SGLT2 Inhibitor (Glifozin, i.e. Dapagliflozin)
All patients with T2DM and CKD

Question 14

When should you refer a patient with CKD for secondary care support (4)?

Answer 14

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

Question 15

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?

Answer 15

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)

Question 16

How should a patient with hypothyroidism be advised to take their levothyroxine?

Answer 16

Empty stomach
First thing in a morning before food or other medication

Question 17

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?

Answer 17

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

Question 18

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?

Answer 18

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)

Question 19

What blood tests should you monitor for a patient with beta thalassemia and what results would you expect?

Answer 19

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

Question 20

Name 3 presenting features that would make you consider PCOS?

Answer 20

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

Question 21

What is the diagnostic criteria for PCOS?

Answer 21

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)

Question 22

What key investigations should be performed when considering PCOS as a diagnosis? (3)

Answer 22

USS
Total testosterone
Sex hormone binding globulin (SHBG)

FSH/ LH/ TFT’s and prolactin - rule out other causes oligo or amenorrhoea

Question 23

You have just diagnosed your patient with PCOS, what should be done with regard to counselling on long complications? (4)

Answer 23

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

Question 24

How do you manage oligo or ammenorhoea in a newly diagnosed PCOS patient?

Answer 24

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

Question 25

A patient has a new beta thalassemia trait diagnosis - what action do you need to advise?

Answer 25

Inform when wishing to conceive will need to test baby
No actions needed til then

Question 26

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?

Answer 26

TSH receptor antibodies
- Graves = 80% of hyperthyroidism (10:1 female), most common 30-50
- Commonly with other autoimmune conditions

Question 27

What is the role of TPO antibodies in diagnosing thyroid disease?

Answer 27

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

Question 28

Name three complications of hypothyroidism?

Answer 28

Dyslipidaemia, metabolic syndrome, coronary heart disease, stroke, heart failure
Neurological and cognitive impairments
Adverse maternal and fetal outcomes in pregnancy.

Question 29

Name three possible signs or symptoms of graves orbitopathy?

Answer 29

Excessive eye watering
Double vision, change in visual acuity or color vision,
Eyelid retraction or lid lag
Proptosis

Question 30

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?

Answer 30

Refer to specialist to initiate carbimazole/ propylthiouracil

Can offer beta blocker to help with symptoms

Question 31

A patient has subclinical hyperthyroidism. What is the criteria for referral to endocrinology?

Answer 31

Two TSH readings <0.1 - 3 months apart + evidence of thyroid disease (symptoms, goitre etc)

Question 32

A 32 year old woman with subclinical hyperthyroidism presents as she is planning a pregnancy. What is the referral timeline?

Answer 32

Urgent referral for all patients with any hyper/hypothyroid who are planning pregnancy or pregnant to endocrinology

Question 33

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?

Answer 33

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

Question 34

How should vaping be considered when looking at UKMEC for contraception?

Answer 34

FSRH says treat vaping the same as smoking when assessing UKMEC risk

Question 35

What are the simon Broome criteria?

Answer 35

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

Question 36

Name 5 possible eczema triggers?

Answer 36

Irritants (Clothes, allergens, soaps)
Inhalents (pollen, pets etc)
Hormones
Climate (cold usually worse)
Stress/ illness
Diet (milk, egg, wheat, penut)

Question 37

What is the common genetic pattern of familial hypercholesterolemia?

Answer 37

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).