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Summary General Medicine course
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General Medicinesummary
HNE-27806 | Feb 2021
Table of Contents
Chapter 1. GP patients, Examination and Diagnostics............................................................................5
The definition of health......................................................................................................................5
The patient in the general practice.....................................................................................................5
The diagnostic process........................................................................................................................5
The medical consultation....................................................................................................................6
Information-gathering....................................................................................................................6
Clinical diagnostic reasoning...............................................................................................................8
Communicating a diagnosis................................................................................................................9
Diagnosis, artificial intelligence and the future of medicine...............................................................9
Chapter 2. Diabetes..............................................................................................................................10
Introduction to diabetes...................................................................................................................10
Diabetes prevalence, incidence and mortality..................................................................................11
Clinical skills for diabetes mellitus....................................................................................................12
Physiology of insulin structure, secretion and action.......................................................................12
The insulin receptor......................................................................................................................13
Glucose metabolism.....................................................................................................................13
Hormonal regulation....................................................................................................................14
Classification of diabetes..................................................................................................................14
Type 1 diabetes mellitus...............................................................................................................14
Type 2 diabetes mellitus...............................................................................................................15
Monogenic diabetes mellitus........................................................................................................17
Clinical approach to the person with diabetes..................................................................................17
Diagnosis and investigations.........................................................................................................17
Prevention of type 2 diabetes...........................................................................................................17
Management of diabetes..................................................................................................................18
Hypoglycaemia.............................................................................................................................18
Non-insulin injectable therapies for type 2 diabetes....................................................................19
Which drug and when?.................................................................................................................19
1
, Diabetic metabolic emergencies.......................................................................................................20
Diabetic ketoacidosis....................................................................................................................20
Hyperosmolar hyperglycaemic state............................................................................................20
Lactic acidosis...............................................................................................................................20
Complications of diabetes................................................................................................................21
Chapter 3. Cardiovascular disease........................................................................................................24
Types of CVD.....................................................................................................................................24
CVD risk managements.....................................................................................................................25
Hypertension....................................................................................................................................25
Measurement of blood pressure..................................................................................................26
Causes of raised blood pressure...................................................................................................26
Thresholds and targets in hypertension.......................................................................................27
Hypertensive target organ damage..............................................................................................27
Treatment.....................................................................................................................................27
Lipid and metabolic disorders...........................................................................................................27
Disorders of lipid metabolism.......................................................................................................28
Thrombosis.......................................................................................................................................29
Cardiology.........................................................................................................................................31
Clinical approach to the patient with heart disease.....................................................................33
Cardiac arrhythmias......................................................................................................................34
Heart failure..................................................................................................................................35
Myocardial infarction (CHD).........................................................................................................36
Angina (CAD).................................................................................................................................37
Chapter 4. Respiratory Diseases...........................................................................................................38
Clinical skills for respiratory medicine..............................................................................................38
Clinical approach to the patient with respiratory disease................................................................39
Diseases of the upper respiratory tract............................................................................................41
Rhinitis..........................................................................................................................................41
Influenza.......................................................................................................................................42
Acute bronchitis (obstructive respiratory disease).......................................................................42
Obstructive respiratory disease........................................................................................................42
Asthma.........................................................................................................................................42
Chronic bronchitis/COPD..............................................................................................................43
Obstructive sleep apnoea.............................................................................................................44
Smoking............................................................................................................................................45
Toxic effects..................................................................................................................................45
2
, Respiratory infection........................................................................................................................45
Pneumonia...................................................................................................................................45
Pleural disease..................................................................................................................................46
Pneumothorax..............................................................................................................................46
Diseases caused by asbestos........................................................................................................47
Chapter 5. Tropical diseases: Malaria, Tuberculosis, HIV.....................................................................47
Introduction to infectious diseases...................................................................................................47
Clinical skills for infectious disease...................................................................................................48
Clinical approach to the patient with a suspected infection.........................................................48
Epidemiology and prevention of infections..................................................................................49
Malaria..............................................................................................................................................49
Tuberculosis......................................................................................................................................51
HIV....................................................................................................................................................52
Chapter 6. Gastrointestinal Diseases....................................................................................................53
Clinical skills for gastroenterology....................................................................................................53
Principal investigations.................................................................................................................53
Imaging.........................................................................................................................................54
Peptic ulcer disease......................................................................................................................54
Coeliac disease (sprue).................................................................................................................55
Colon cancer.................................................................................................................................56
Inflammatory bowel disease (IBD)....................................................................................................57
Crohn’s disease.............................................................................................................................57
Ulcerative colitis...........................................................................................................................58
Irritable bowel syndrome (IBS).....................................................................................................58
Chapter 7. Neurology...........................................................................................................................59
Stroke...............................................................................................................................................59
Parkinson’s disease...........................................................................................................................60
Meningitis.........................................................................................................................................61
Chapter 8. Obesity................................................................................................................................62
Introduction......................................................................................................................................62
Prevalence and risk factors of obesity..............................................................................................62
Treatment of obesity........................................................................................................................63
Chapter 9. Cancer.................................................................................................................................63
Introduction......................................................................................................................................63
Colorectal cancer..............................................................................................................................64
3
, Introduction..................................................................................................................................64
Risk factors for colorectal cancer..................................................................................................64
Warning signs...............................................................................................................................64
Diagnosis and treatment..............................................................................................................64
Breast cancer....................................................................................................................................65
Introduction..................................................................................................................................65
Why and where does breast cancer occur?..................................................................................65
Ductal and lobular carcinoma.......................................................................................................65
Warning signs...............................................................................................................................66
Risk factors for breast cancer.......................................................................................................66
Glossary General Medicine...................................................................................................................67
Examination and diagnostics............................................................................................................67
Diabetes............................................................................................................................................68
CVD...................................................................................................................................................68
Respiratory diseases.........................................................................................................................68
Tropical diseases...............................................................................................................................69
GI diseases........................................................................................................................................69
Neurology.........................................................................................................................................70
4
,Chapter 1. GP patients, Examination and
Diagnostics
The definition of health
The definition of individual health that is used for a long time, comes from the WHO (1946), which
states: health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity. This definition does not take into account the ability to cope with
chronic diseases or abilities (health is not static). Therefore, the BMJ formulated a new definition in
2011: health is the ability to adapt and self manage in the face of social, physical and emotional
challenges.
The patient in the general practice
In the Netherlands, there are about 5.000 GP practices. About ⅟3th of the registered patients is
between 18-44 years (mean age 42). 78% of the registered patients visited the GP in 2019, with an
average number of visits of 5. Elderly (>85 years) have an average number of 15 visits.
The number of children visiting a GP is declining over the years, elderlies
are visiting GPs more often in the last decades.
The most common reasons for GP visits are:
1. Hypertension
2. Urinary tract infections
3. Diabetes
4. Coughing
5. Fatigue
6. Acute upper airway infections
This list is consistent over the years. There are guidelines for treating these diseases in a standard
manner: NHG-standaarden.
The diagnostic process
Diagnosis is often an iterative process, in which information is gathered, interpreted and integrated
to form a working diagnosis, and then communicated and acted on through treatment. All the time,
the working diagnosis is refined or revised using newly gathered information, including the patient’s
response to treatment.
5
,The medical consultation
First impressions are important when meeting a health clinician as patients need to be able to share
their most intimate and worrying problems. It is helpful when staff members introduce themselves.
Furthermore, expressing empathy, support or care for the patient can be helpful in ensuring that a
good report is established, before proceeding to talk about the problem. The GP may use the ICE
technique during a patient history. ICE = ideas, concerns, expectations of the patient. This can help to
build a therapeutic relationship.
Information-gathering
The diagnostic process has three parts: history,
examination and investigation.
The history
The diagnostic process starts with a history, which includes
everything the patient can tell you (listen). This is also
called taking the anamnesis.
At the start of the consultation the clinician should avoid interrupting the patient for as long as
possible. Patients often mentally rehearse a script relating to the symptoms or problems they wish to
describe. An early interruption may throw them off course and cause them to forget key points,
leaving them feeling dissatisfied with the interaction. The term ‘the golden minute’ has been coined
to encourage clinicians to allow patients to tell their story uninterrupted for at least 1 minute. It is
estimated that up to 80% of the diagnosis can be made on the basis of a careful history alone.
Strategies in history-taking: begin with open questions; emphasize your active listening; respond to
the patient’s body language; empathise; summarise; signpost; use plain language.
During history-taking, the GP asks about the:
Duration and severity of symptoms
Localisation of pain (situation)
Family history and smoking behaviour (occupation). Family history is especially relevant
when assessing younger patients or when the differential diagnosis includes possible genetic
conditions.
Medication
Past medical history
6
, Establishing the pattern in which symptoms have
developed is often one of the most helpful parts of
the history in helping to form a diagnosis.
Physical examination
The history is followed by examination, which involves the senses of the GP (what you can see, hear,
feel and smell). It is used to confirm or refute the initial diagnosis made from the history. A physical
examination always consists of four parts:
Inspection: look at/in the patient (discolouration of skin, problems with posture, tremors)
Auscultation: listen for example with stethoscope (heart, breathing and gurgling sounds)
Percussion: tap on patient and listen to the sound (for size, position and density) (tapping on
abdomen or chest)
Palpation: feel (lumps, firmness, nodules)
Using the history and examination, the GP can come to the differential diagnosis the distinguish
of a certain disease or situation from others that present similar signs or symptoms (primary care).
For example, a patient is coughing for over 3 weeks. The GP looks whether the chest is normal and
smoking history, and comes up with a list of differential diagnosis. Other factors are also taken into
account: season, age, likelihood.
Investigation
To know which of the differential diagnoses matches the patient, the patient may be sent to the
hospital for investigation. In the hospital, medical specialists further investigate the patient
(secondary care). Think about laboratory methods (blood, urine), tissue biopsy, imaging techniques
(X-ray, CT-scan, PET scan, MRI), spirometry and ECG.
Imaging techniques
X-rays are a form of high energy electromagnetic radiations which forms a 2D picture. It has higher
energy than visible light (shorter wavelengths) and lower than gamma-rays. X-rays can penetrate
many kinds of matter. With X-rays, images of organs, such as bones, can be made. Dense materials
and materials with a high atom number absorb X-rays pretty well (bones). Soft tissue is not that
dense and contains lower atom number elements, so the X-rays penetrate through this soft tissue.
CT scan uses X-rays to make a 3D image of the body, thus X-rays are sent from different angles. The
image is very detailed. Contrast material may be used to detect organs easier. CT scans have extreme
accuracy and can therefore be used in many cases: internal injuries, detection of cancer, muscle and
bone disorders. Pregnant women should not undergo CT scans in order to avoid radiation.
7
, An MRI scan is a technique used to generate an image of one’s body non-invasively. Strong radio
waves are sent through the body during a scan, hydrogen atoms absorb this energy and sent it back
when the waves stop. People with metal implements and pregnant women cannot undergo an MRI
scan due to the powerful magnetic force.
A CT scan has a higher resolution than MRI, but the risk is lower in MRI.
With a PET scan, a patient injects a radioactive tracer. This tracer is absorbed by tissues in the body.
A PET scanner can highlight these tracers and see how well organs and tissues perform. They can
measure blood flow, oxygen use and glucose metabolism. PET scans can show problems and
complications at a cellular level. The resolution is lower than MRI and CT scan, it makes a functional
image. Allergic reactions to tracers might occur.
Clinical diagnostic reasoning
Forming a diagnosis involves a complex process of reasoning. Large amounts of information gathered
from the history, examination and investigation results need to be assimilated and synthesised into a
working diagnosis.
There are different models of diagnosis. A traditional model suggests that a clinician should begin by
considering all possible causes of a particular presenting symptom, and use information gathered
from the diagnostic process to include and exclude likely causes gradually, using probabilistic
reasoning, until only one remains. An alternative model suggests that diagnosis proceeds instead
primarily by pattern recognition, that allows humans to compare patients with similar situations
encountered in the past. This forms an initial impression which is then tested as further information
becomes available.
In reality, a combination of these two approaches generally occurs: an initial rapid impression is
formed, which is subsequently revised. This ‘back to drawing board’ approach has been suggested as
the best model for safe diagnosis.
It has been estimated that 10-15% of medical diagnoses are wrong. This may cause significant patient
harm. There are common cognitive biases, such as anchoring (relying too heavily on a piece of
information), framing (making decisions in different ways) and optimism (assuming that negative
outcomes will occur at a lower rate than they really do. Various strategies for avoiding bias are:
Adopting an iterative approach: re-evaluation of previous diagnoses
Team discussions
Diagnostic criteria and guidelines
Considering patient problems in language devoid of assumption
Using lists of disease classes to avoid jumping to conclusions
Diagnostic criteria have a range of functions beyond treating individual patients, including a role in
public health (in the compilation of statistics for monitoring trends in the incidence and distribution
of diseases), research (to allow study of diseases and treatments in well-defined disease
populations), and remuneration or reimbursement (in many health systems, payment to healthcare
providers is on the basis of diagnostic codes assigned to patients receiving care).
Overdiagnosis refers to a diagnosis that is correctly assigned on the basis of a screening programme,
but is inappropriate because it is unlikely ever to cause harm to the patient in question. For example,
a 93-year-old man with dementia visited his GP and it shows that he has a heart rate of 66 bpm. A
8
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