chronic-care

name	chronic-care
description	Comprehensive chronic disease and nodule management. Supports hypertension, diabetes, cardiovascular disease, thyroid nodule (TI-RADS), breast nodule (BI-RADS), lung nodule (Fleischner guidelines), chronic prostatitis (NIH-CPSI), and chronic allergic conditions. Provides condition-specific monitoring, complication screening, personalized targets, and evidence-based lifestyle recommendations. Triggers on: hypertension, diabetes, high blood pressure, high blood sugar, thyroid nodule, breast nodule, lung nodule, prostatitis, prostate, chronic condition, disease management.
allowed-tools	["bash","glob","read"]
version	1.0.0

Chronic Care — Your Chronic Condition & Nodule Companion

Specialized skill for managing chronic diseases and nodules with personalized care plans, complication prevention, and evidence-based targets.

📋 Supported Conditions

Cardiometabolic Conditions

• Hypertension (all stages per ACC/AHA 2017)
• Diabetes Type 1 & 2 (ADA Standards of Care)
• Prediabetes / Insulin Resistance
• Cardiovascular Disease (secondary prevention)
• Heart Failure (stable, NYHA I-II)
• Chronic Kidney Disease (stage 1-3)

Nodule Management (NEW)

• Thyroid Nodule (TI-RADS classification, ACR guidelines)
• Breast Nodule (BI-RADS classification, ACR guidelines)
• Lung Nodule (Fleischner Society guidelines)

Urological Conditions

• Chronic Prostatitis (NIH-CPSI scoring)
• Benign Prostatic Hyperplasia (IPSS scoring)

Allergic Conditions

• Allergic Rhinitis (seasonal/perennial)
• Food Allergies (IgE-mediated)
• Eczema / Atopic Dermatitis

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🫀 Hypertension Management

BP Classification (ACC/AHA 2017)

Category	Systolic	Diastolic	Action
Normal	<120	<80	Maintain healthy lifestyle
Elevated	120-129	<80	Lifestyle modifications
Stage 1	130-139	80-89	Lifestyle + consider medication
Stage 2	≥140	≥90	Medication + lifestyle
Crisis	≥180	≥120	Emergency evaluation

Target BP by Risk Profile

Risk Category	Target BP
Low CV risk (<10%)	<140/90 mmHg
Moderate risk (10-20%)	<130/80 mmHg
High risk (>20%)	<130/80 mmHg
Diabetes + HTN	<130/80 mmHg
CKD + HTN	<130/80 mmHg
Elderly (≥65)	<130/80 mmHg (if tolerated)

Monitoring Schedule

Parameter	Frequency	Target
Home BP	2x/day (morning/evening)	<130/80 mmHg
Weight	Weekly	Stable
Sodium intake	Daily log	<2300 mg/day
Exercise	Weekly log	150 min/week moderate
Medication adherence	Daily	>90%

Lifestyle Recommendations

DASH Diet Components:

• Vegetables: 4-5 servings/day
• Fruits: 4-5 servings/day
• Whole grains: 6-8 servings/day
• Low-fat dairy: 2-3 servings/day
• Lean protein: ≤6 servings/day
• Sodium: <2300 mg/day (ideal <1500 mg)

Exercise Prescription:

• Aerobic: 150 min/week moderate OR 75 min/week vigorous
• Resistance: 2-3 days/week
• Flexibility: Daily stretching

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🩸 Diabetes Management

Glucose Targets (ADA Standards)

Population	Fasting BG	Post-Meal BG	HbA1c
Most adults	80-130 mg/dL	<180 mg/dL	<7.0%
Pregnancy	<95 mg/dL	<140 mg/dL	<6.5%
Elderly/frail	90-150 mg/dL	<200 mg/dL	<8.0%
High hypo risk	100-180 mg/dL	<200 mg/dL	<7.5%

Time-in-Range (CGM Metrics)

Range	Target	Clinical Significance
70-180 mg/dL	>70%	Time in target range
<70 mg/dL	<4%	Hypoglycemia
<54 mg/dL	<1%	Severe hypoglycemia
>180 mg/dL	<25%	Hyperglycemia
>250 mg/dL	<5%	Severe hyperglycemia

Complication Screening Schedule

Complication	Screening Test	Frequency
Retinopathy	Dilated eye exam	Annually
Nephropathy	UACR + eGFR	Annually
Neuropathy	Monofilament test	Annually
CVD	BP, lipids, ECG	Each visit / Annually
Foot ulcers	Comprehensive foot exam	Annually (high risk: quarterly)

Sick Day Management

When Ill (fever, vomiting, infection):

1. Monitor glucose every 2-4 hours
2. Check ketones if glucose >250 mg/dL
3. Continue basal insulin (may need correction doses)
4. Stay hydrated (sugar-free fluids)
5. Contact doctor if:
   • Glucose >300 mg/dL despite corrections
   • Moderate/large ketones
   • Unable to keep fluids down
   • Fever >38.5°C for >24 hours

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🦋 Thyroid Nodule Management

TI-RADS Classification (ACR 2017)

TI-RADS Level	Points	Malignancy Risk	Management
TR1	0	<2%	Benign, no FNA
TR2	2	<2%	Not suspicious, no FNA
TR3	3	~5%	Follow-up if ≥2.5cm, FNA if ≥2.5cm
TR4	4-6	5-20%	Follow-up if ≥1.5cm, FNA if ≥1cm
TR5	≥7	>20%	Follow-up if ≥1cm, FNA if ≥1cm

Ultrasound Features (Point System)

Feature	0 Points	1 Point	2 Points	3 Points
Composition	Cystic	Spongiform	Mixed	Solid
Echogenicity	Anechoic	Hyperechoic	Isoechoic	Hypoechoic
Shape	-	-	Wider-than-tall	Taller-than-wide
Margin	Smooth	-	Ill-defined	Extrathyroidal
Echogenic Foci	None	Large	Punctate	-

Follow-Up Schedule

TI-RADS	Size	Initial Follow-up	Ongoing
TR3	<2.5cm	1 year	Every 1-2 years if stable
TR3	≥2.5cm	Consider FNA	-
TR4	<1.5cm	1 year	Every 1-2 years if stable
TR4	≥1.5cm	Consider FNA	-
TR5	<1cm	1 year	Annual for up to 5 years
TR5	≥1cm	FNA recommended	-

Growth Definition

Significant Growth:

• ≥20% increase in two dimensions, OR
• ≥50% increase in volume, OR
• New suspicious features

Action for Growth:

• Upgrade TI-RADS category
• Consider FNA if not previously done
• Shorten follow-up interval

Patient Education

Reassurance Points:

• 90-95% of thyroid nodules are benign
• TR3 has <5% malignancy risk
• Most nodules don't require surgery
• Regular follow-up is key

When to Seek Care:

• Rapid nodule growth
• Hoarseness or voice changes
• Difficulty swallowing
• Neck lymph node enlargement

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🎗️ Breast Nodule Management

BI-RADS Classification (ACR)

BI-RADS	Malignancy Risk	Management
0	Incomplete	Additional imaging needed
1	0%	Negative, routine screening
2	0%	Benign, routine screening
3	<2%	Probably benign, 6-month follow-up
4A	2-10%	Low suspicion, biopsy consideration
4B	10-50%	Moderate suspicion, biopsy recommended
4C	50-95%	High suspicion, biopsy strongly recommended
5	>95%	Highly suggestive of malignancy
6	100%	Known biopsy-proven malignancy

Imaging Modality by Age

Age	Primary Modality	Additional
<30	Ultrasound	MRI if high risk
30-39	Ultrasound + Mammogram	-
≥40	Mammogram + Ultrasound	MRI if dense breasts

Follow-Up Schedule

BI-RADS	Follow-up	Duration
1-2	Routine screening	Annual (age ≥40)
3	6, 12, 24 months	If stable at 2 years → routine
4A-C	Biopsy	Within 2-4 weeks
5	Biopsy + Oncology	Immediate

Cyclical Breast Changes

Fibrocystic Changes (Common, Benign):

• Timing: Worsens before menstruation
• Symptoms: Lumpiness, tenderness, bilateral
• Management: Supportive bra, reduce caffeine, OTC pain relief

When to Evaluate:

• New lump persisting after menses
• Dominant mass (different from surrounding tissue)
• Nipple discharge (especially bloody)
• Skin changes (dimpling, redness)

Patient Education

Self-Awareness (not formal self-exam):

• Know your normal breast texture
• Report new, persistent changes
• Don't panic—most lumps are benign

Risk Reduction:

• Maintain healthy weight
• Limit alcohol (<1 drink/day)
• Regular exercise
• Breastfeeding (if possible)

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🫁 Lung Nodule Management

Fleischner Society Guidelines (2017)

Solid Nodules

Nodule Size	Low Risk Patient	High Risk Patient
<6mm	No routine follow-up	Optional CT at 12 months
6-8mm	CT at 6-12 months	CT at 6-12 months, then 18-24 months
>8mm	Consider 3-month CT, PET, or biopsy	Consider 3-month CT, PET, or biopsy

Subsolid Nodules

Type	Size	Management
Pure GGN	<6mm	No routine follow-up
Pure GGN	≥6mm	CT at 6-12 months, then every 2 years until 5 years
Part-solid	≥6mm	CT at 3-6 months, then annual for 5 years

Risk Stratification

Low Risk:

• Minimal or no smoking history
• Age <50 years
• No family history of lung cancer
• No other risk factors

High Risk:

• Significant smoking history (≥20 pack-years)
• Age ≥50 years
• Family history of lung cancer
• Occupational exposures (asbestos, radon)
• Personal history of cancer

Growth Assessment

Significant Growth:

• ≥2mm increase in diameter
• Doubling time 20-400 days (concerning for malignancy)
• New solid component in subsolid nodule

Action for Growth:

• Shorten follow-up interval
• Consider PET-CT
• Biopsy or surgical consultation

Smoking Cessation (Critical)

5 A's Approach:

1. Ask about tobacco use
2. Advise to quit
3. Assess readiness to quit
4. Assist with quit attempt
5. Arrange follow-up

Pharmacotherapy Options:

• Nicotine replacement therapy (patch, gum, lozenge)
• Varenicline (Chantix)
• Bupropion (Zyban)

Patient Education

Reassurance:

• Most small nodules (<6mm) are benign
• Even larger nodules often represent old infections
• Follow-up is essential but don't panic

Warning Signs:

• Persistent cough
• Coughing up blood
• Chest pain
• Unexplained weight loss
• Shortness of breath

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🚹 Chronic Prostatitis Management

NIH-CPSI Scoring System

Domains:

1. Pain (0-9 points)
   • Perineal, testicular, suprapubic, low back pain
   • Pain during/after ejaculation
2. Urinary (0-6 points)
   • Incomplete emptying
   • Frequency
3. Quality of Life (0-12 points)
   • Symptom impact
   • Life satisfaction
   • Worry about symptoms

Total Score: 0-43

Severity	Score Range
Mild	1-9
Moderate	10-18
Severe	19-43

Classification (NIH)

Category	Name	WBC in EPS	Culture
I	Acute Bacterial	Positive	Positive
II	Chronic Bacterial	Positive	Positive
IIIA	Inflammatory CPPS	Positive	Negative
IIIB	Non-inflammatory CPPS	Negative	Negative
IV	Asymptomatic	Positive	Negative

CPPS = Chronic Pelvic Pain Syndrome

Treatment Approach by Category

Category II (Chronic Bacterial):

• Antibiotics: 4-6 weeks (fluoroquinolone or TMP-SMX)
• Alpha-blocker if voiding symptoms
• Anti-inflammatory for pain

Category III (CPPS - Most Common):

• Multimodal approach (UPOINT system):
  • Urinary: Alpha-blockers (tamsulosin)
  • Psychosocial: Stress management, CBT
  • Organ-specific: Quercetin, pollen extract
  • Infection: Trial antibiotics (if never tried)
  • Neurologic: Neuropathic pain agents (gabapentin, amitriptyline)
  • Tenderness: Pelvic floor physical therapy

Lifestyle Recommendations

Dietary Modifications:

• Limit: Alcohol, caffeine, spicy foods, acidic foods
• Increase: Water (2-3L/day), omega-3 fatty acids
• Consider: Anti-inflammatory diet

Physical Measures:

• Warm sitz baths (15-20 min, 1-2x/day)
• Avoid prolonged sitting (use cushion)
• Regular exercise (avoid cycling if worsens symptoms)
• Pelvic floor relaxation exercises

Stress Management:

• Mindfulness meditation
• Deep breathing exercises
• Cognitive behavioral therapy
• Regular sleep schedule

Monitoring Schedule

Parameter	Frequency
NIH-CPSI score	Every 4-6 weeks
Urinalysis	Every 3 months
PSA (if age ≥50)	Annually
Post-void residual	If voiding symptoms worsen

When to Refer to Urology

• NIH-CPSI ≥20 despite conservative management
• Recurrent urinary tract infections
• Elevated PSA or abnormal DRE
• Hematuria
• Suspected abscess
• Consideration for procedural interventions

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🤧 Allergy Management

Allergic Rhinitis Classification

Type	Timing	Common Triggers
Seasonal	Spring/Fall	Tree pollen, grass, ragweed
Perennial	Year-round	Dust mites, pet dander, mold
Occupational	Work days	Chemicals, dust, latex

ARIA Classification

Severity	Sleep	Daily Activities	Symptoms
Mild	Normal	Normal	Bother some
Moderate-Severe	Disturbed	Impaired	Troublesome

Stepwise Treatment (ARIA Guidelines)

Step 1 (Mild Intermittent):

• Oral antihistamine (cetirizine, loratadine, fexofenadine)
• Avoid triggers

Step 2 (Moderate-Severe or Persistent):

• Intranasal corticosteroid (fluticasone, mometasone)
• Continue oral antihistamine

Step 3 (Refractory):

• Add intranasal antihistamine (azelastine)
• Consider combination spray (steroid + antihistamine)
• Allergen immunotherapy consideration

Step 4 (Severe Refractory):

• Allergy testing and immunotherapy
• Biologic agents (omalizumab for severe cases)

Preemptive Treatment

For Seasonal Allergies:

• Start intranasal steroid 1-2 weeks BEFORE pollen season
• Continue daily throughout season
• Add oral antihistamine for breakthrough symptoms

Trigger Avoidance

Pollen:

• Keep windows closed during high pollen days
• Shower and change clothes after being outdoors
• Use HEPA air filter
• Check pollen count forecasts

Dust Mites:

• Encase mattress and pillows
• Wash bedding weekly in hot water (>55°C)
• Remove carpets from bedroom
• Maintain humidity <50%

Pet Dander:

• Keep pets out of bedroom
• HEPA air filter
• Wash hands after pet contact
• Consider rehoming if severe

Food Allergy Management

Common Triggers:

• Milk, eggs, peanuts, tree nuts
• Soy, wheat, fish, shellfish

Management:

• Strict avoidance
• Read food labels carefully
• Carry epinephrine auto-injector (if anaphylaxis risk)
• Wear medical alert bracelet

Emergency Action Plan:

1. Recognize symptoms (hives, swelling, difficulty breathing)
2. Administer epinephrine immediately
3. Call emergency services
4. Lie down with legs elevated
5. Second dose if no improvement in 5-10 minutes

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🔗 Cross-Domain Correlation Analysis

Hypertension Correlations

Factor	Correlation	Recommendation
Sodium intake	r = 0.6-0.7 (positive)	Reduce to <2300 mg/day
Exercise frequency	r = -0.5 to -0.7 (negative)	150 min/week moderate
Sleep quality	r = -0.6 to -0.7 (negative)	Prioritize 7-8 hours
Stress level	r = 0.4-0.6 (positive)	Daily meditation 10 min
Alcohol intake	r = 0.4-0.5 (positive)	Limit to ≤2 drinks/day
Potassium intake	r = -0.4 to -0.5 (negative)	Increase potassium-rich foods

Diabetes Correlations

Factor	Correlation	Recommendation
Carb intake	r = 0.6-0.7 (positive)	Control refined carbs
Post-meal exercise	r = -0.5 to -0.6 (negative)	15-30 min walk after meals
Medication adherence	r = 0.7-0.8 (positive)	Set reminders, pill organizer
Fiber intake	r = -0.4 to -0.5 (negative)	25-30g fiber/day
Sleep duration	r = -0.4 to -0.5 (negative)	7-8 hours sleep
Stress level	r = 0.5-0.6 (positive)	Stress management techniques

Nodule-Specific Correlations

Thyroid Nodule:

Factor	Correlation	Recommendation
Iodine intake	U-shaped	150 mcg/day (not too little, not too much)
TSH level	r = 0.5 (positive)	Monitor TSH every 6-12 months
Cancer anxiety	r = 0.6 (positive)	Reassurance: TR3 <5% risk

Breast Nodule:

Factor	Correlation	Recommendation
Cycle phase	Cyclical	Track timing; many are fibrocystic changes
Caffeine	r = 0.3 (positive)	Consider reduction if symptomatic

Lung Nodule:

Factor	Correlation	Recommendation
Smoking history	r = 0.6-0.8 (positive)	Critical: Smoking cessation
Nodule growth	Variable	Follow Fleischner guidelines

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📊 Output Format

Every chronic care consultation produces:

# [Condition] Management Report

**Date**: YYYY-MM-DD
**Condition**: [Hypertension / Diabetes / Thyroid Nodule / etc.]

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## 🚨 Risk Assessment

**Current Status**: [Controlled / Needs Attention / Urgent]
**Risk Level**: 🟢 Low / 🟡 Medium / 🔴 High

**Key Concerns**:
- [Concern 1]
- [Concern 2]

---

## 📈 Current Metrics

| Parameter | Current | Target | Status |
|-----------|---------|--------|--------|
| [Parameter 1] | [Value] | [Target] | ✅/⚠️/❌ |
| [Parameter 2] | [Value] | [Target] | ✅/⚠️/❌ |

---

## 🔗 Correlation Insights

### [Factor A] ↔ [Condition]
**Correlation**: r = [value] ([Strength])
**What this means**: [Interpretation]
**Action**: [Specific recommendation]

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## 📋 Action Plan

### Today
- [ ] [Action 1]
- [ ] [Action 2]

### This Week
- [ ] [Action 3]
- [ ] [Action 4]

### This Month
- [ ] [Follow-up test/appointment]
- [ ] [Goal]

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## 📅 Follow-Up Schedule

| Test/Visit | Due Date | Status |
|------------|----------|--------|
| [Test 1] | YYYY-MM-DD | Due/Completed |
| [Test 2] | YYYY-MM-DD | Due/Completed |

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## ⚠️ When to Seek Immediate Care

- [Red flag symptom 1]
- [Red flag symptom 2]
- [Red flag symptom 3]

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## 📚 Patient Education

[Condition-specific education points]

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**Disclaimer**: This analysis is based on your provided health data and is for informational purposes only. It does not replace professional medical diagnosis or treatment. Always consult your healthcare provider for medical concerns.

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🛡️ Safety Boundaries

✅ Can Do

• Track and trend condition-specific metrics
• Provide evidence-based lifestyle recommendations
• Remind about follow-up schedules per guidelines
• Explain classification systems (TI-RADS, BI-RADS, etc.)
• Correlate lifestyle factors with condition control
• Generate action plans

❌ Cannot Do

• Diagnose conditions
• Prescribe or adjust medications
• Order diagnostic tests
• Interpret biopsy results
• Replace specialist consultation
• Predict malignancy

🚨 Emergency Triggers

Hypertension Crisis:

• BP ≥180/120 mmHg → Seek emergency care

Diabetes Emergency:

• Glucose >300 mg/dL with symptoms → Urgent care
• Glucose <50 mg/dL → Immediate treatment

Nodule Red Flags:

• Rapid growth
• New neurological symptoms
• Unexplained weight loss
• Night sweats

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🔗 Cross-References

Skill	Relationship
musculoskeletal-care	Osteoporosis bone density management, fracture risk assessment
fitness-coach	Exercise prescription for chronic conditions
medication-manager	Medication adherence tracking
nutrition-advisor	DASH diet, diabetic diet, calcium/Vitamin D
vital-monitor	BP, glucose trend tracking
preventive-care	Screening schedules

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📚 References

Clinical Guidelines

• Hypertension: ACC/AHA 2017 Guidelines
• Diabetes: ADA Standards of Care 2026
• Thyroid Nodules: ACR TI-RADS 2017
• Breast Imaging: ACR BI-RADS Atlas 5th Edition
• Lung Nodules: Fleischner Society Guidelines 2017
• Prostatitis: NIH-CPSI, EAU Guidelines
• Allergic Rhinitis: ARIA Guidelines 2025

Risk Calculators

• ASCVD Risk Calculator
• Framingham Risk Score
• CHA2DS2-VASc Score (if applicable)

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Version: v2.0 Created: March 2026 Maintainer: Family Doctor Team