Samenvatting - Class notes - General Medicine

• 1613343600 Examination and diagnosis

• What is the current definition of health (and who made it)

  The ability to adapt and self manage in the face of social, physical, and emotional challenges (BMJ, 2011)
• How does the current definition of health differ from the 1946-definition of health by the WHO?

  Definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 1946)
  
  Differ: The Who definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleageus propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical and emotional challenges.
• What are the most common reasons for GP visits?

  1. Hypertension 
     
  2. Urinary tract infections 
  3. Diabetes
  4. Coughing 
  5. Fatigue 
  6. Acute upper airway infections 
• The GP is part of ...... Care
• What does the acronym ICE stand for?

  Idea Concerns Expectations 
  
  What are the ideas, concerns or expectations of the patient?
  
  Voorbeeld met jongetje met leukemie, dokter maakt zich zorgen over het process en de chemo etc maar het jongetje maakt zich zorgen over of hij nog wel kan zwemmen in de zomer en lekker naar het strand kan gaan. Door naar ICE te vragen kun je meer betekenen voor de patiënt. 
• Which 3 steps are made in the diagnostic process?

  1. History - everything the patient can tell you (GP)
     
  2. Examination - what you can see, hear, feel, smell (GP)
  1. Inspection - kijken  
  2. Auscultation - horen 
  3. Percussion - kloppen + luisteren naar de geluiden 
  4. Palpation - voelen en soms druk uitoefenen  
  3. Investigation - imaging or sampling (hospital)
• Where do you need to think about when taking the anamnesis?

  • Duration and severity of symptoms
    
  • Localisation of pain, situation 
  • Family history, smoking, occupation 
  • Medication 
  • Past medical history 
• What is the mechanics of patient history?

  • Chief complaint 
    
  • History of present illness
  • Past medical history 
  • Medications & allergies
  • Family history 
  • Social history 
• 3 strategies to taking a good patient history

  1. Listen well and empathise 
     
  1. listen with your whole body 
  2. keep questions to a minimum 
  2. Summarize 
  1. go over data with the patient 
  3. ICE
  1. ideas
  2. concerns 
  3. expectations
• Out of which parts does a physical examination consists

  • Inspection
    
  • kijken 
  • Auscultation
  • luisteren 
  • Percussion
  • tapping on the patient and listening to the sounds 
  • Palpation
  • voelen 
• What can be further investigations after taking a GP (usually in hospital setting)

  • Laboratory (blood, urine)
    
  • Tissue biopsy 
  • Imaging techniques
  • X-ray or CT-scan 
  • PET scan 
  • MRI 
  • Spirometry 
  • ECG
• X-rays
  

  • Principle
  • Used for imaging what?
  • Resolution ( + or +/- or -)
  • Risk (+ or -)

  Nog
• CT-scan 
  

  • Principle
  • Used for imaging what?
  • Resolution ( + or +/- or -)
  • Risk (+ or -)

  Nog
• PET-scan 
  

  • Principle
  • Used for imaging what?
  • Resolution ( + or +/- or -)
  • Risk (+ or -)

  Nog
• MRI
  

  • Principle
  • Used for imaging what?
  • Resolution ( + or +/- or -)
  • Risk (+ or -)

  Nog

• 1613516400 Diabetes

• The prevalence of diabetes and proportion of type 2 diabetes

  1 in 10 
  
  90%
• The trend in diabetes numbers increase
• What are the consequences of diabetes?

  • Cardiovascular disease
    
  • Blindness
  • Kidney failure 
• What is the involvement of liver, skeletal muscles, fat tissue, intestines and pancreas in diabetes?

  The liver, skeletal muscles and fat tissue are stimulated to take up glucose when insulin is secreted by the pancreas. This secretion happens when food is ingested and absorbed by the intestine, causing the blood glucose to rise.
• How does insulin controls the blood glucose?

  Rising glucose levels stimulates beta-cells in the pancreas to secrete insulin; stimulates uptake of glucose in skeletal muscles, liver, and adipose tissue, and suppresses glucose output of the liver. After a while, insulin levels go down while the liver starts to release glucose again, while glucose uptake in insulin sensitive tissues will be reduced. This all prevents hypoglycemia  (= a to low blood glucose level) and provides glucose to tissues who rely on glucose as an energy source (e.g. the brain).
• Four main types of diabetes

  • Diabetes type 1 
  • usually young
  • Diabetes type 2 --> 90% 
  • older, obese, family history
  • Gastational diabetes
  • Rare types of diabetes
  • genetic
  • pancreas
  • disease
  • medicins
  • toxins
• Common characteristic of diabetes types

  Hyperglycemia
• What are the characteristics of pre-diabetes?

  Increased fasting blood glucose and impaired glucose tolerance
  
  
  
  

  • Pre diabetes is broken down into two subtypes. One type of people were characterized by increased with non diabetic fasting glucose levels, this condition is called impaired fasting glucose. The other type characterized by people with elevated glucose levels after meal ingestion and this condition is called impaired glucose tolerance. Many people are not aware about a pre diabetic state and hence their risk of becoming diabetic.
    
  • Impaired fasting glucose (IFG)
    
  • Impaired glucose tolerance (IGT)
    
• What are the characteristics of type 2 diabetes?

  
  Insulin resistance and inadequate beta-cell function
  
  

  • Insulin action --> insulin resistance
    
  • Beta-cell function --> Beta-cell failure

  
  
  Both of these characteristics are already present in the pre-diabetic state and likely already earlier.
  Hyperglycaemia = increased blood glucose
• What is the prevalence of diabetes worldwide?

  463 million people living with diabetes in 2019, of which 50% is undiagnosed 
  
  In The Netherlands 
  

  • >1.000.000 patients with diabetes
  • more than 350.000 have the disease but are not diagnosed 

  
  
  Especially in Africa, a huge new burden of disease in the next 25 years. 
• What is the percentage of people with type 2 diabetes?

  90%-95%
  
  

  • 1.5 million new patients per year in the US (2018), >90% type 2 diabetes (incidence)
    
  • In US 40% of people will develop (type 2) diabtes during their lifetime (lifetime incidence)
    
• What are the three reasons why the number of diabetics will increase to 700 million in 2045?

  • Increased life expectancy (mensen worden steeds ouder)
    
  • Increasing rate of obesity
  • Growth of the population
• Is CVD typical for affluent countries?

  No
• differences in prevalence between ethnic groups: possible causes

  • Genetics
    
  • socioeconomic status 
• difference between prevalence, prevalence proportion, and incidence

  Prevalence is a number
  Prevalence proportion is in percentage
  Incidence is a number of new cases per year
• How the incidence of diabetes can be reduced

  Prevention of overweight and obesity
• Why does diabetes reduces life expectancy?

  comorbidities such as stroke, kidney disease, neuropathy 
  
  
  (
  

  • Overall life expectancy of a diabetes patient is reduced by 4-6 years
    
  • Diabetes caused 4.2 million deaths in 2019
  • Associated with 11.3% of all global deaths
  • Stroke; blindness; heart attack; Kidney failure; amputation

  )
• 
  
  After studying this chapter you need to know:
  

  • The physical signs of diabetes (see Examination)
    
  • Complications of diabetes
    
  • Molecular structure of insulin, its origin and its function
    
  • Normal values for blood glucose, glucose production and glucose use (see also criteria for diabetes, Box 23.7)
    
  • how blood gluose is regulated in the body (text and Fig 23.5)
    
  • How diabetes is classified
    
  • the difference between type 1 and type 2 diabetes (text and Box 23.5)
    
  • prevalence and possible causes for type 1 diabetes
    
  • prevalence and risk factors for type 2 diabetes (use the box below)
    
  • clinical presentation of diabetes
    
  • how diabetes is diagnosed
    
  • purpose of the 75-g oral glucose tolerance test
    
  • the role of diet in the management of diabetes (note that ‘sugarfree’ products are not mentioned)
    
  • definition of hypoglycaemia, its signs and symptoms, and its relation with insulin
    
  • cause and consequences of diabetic ketoacidosis
    
  • how diabetes can affect the eyes, kidneys, feet, and nerve system (overview, not detail)
    
  • prevalence of diabetic retinopathy
    
  • how diabetes is a risk factor for cardiovascular disease, with normal values in Box 23.26
    
• For type 2 diabetes, what are the main risk factors?

  Ageing, obesity (80-85% of the overall risk of developing type 2 diabetes), diet (saturated fat), physical inactivity
• Based on the risk factors you can conclude that type 2 diabetes is largely preventable