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HNH27806 - general medicine (complete course)
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General medicineLecture 1: Health, patient history, examination and diagnostics:
Health definition:
- WHO definition (1948): “A state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity” → ground breaking formulation
o Overcame negative definition of health absence of disease
▪ People with disease could also see themselves as healthy!
o Included physical, mental and social domains
- Current definition British Medical Journal: “The ability to adapt and self manage in the face of social, physical,
and emotional challenges”
o Definition aimed at the individual, not public health.
Patients in the general practice
- About 5000 GP clinics in the Netherlands
- Mean age registered patients 42 years
o About a third 18-44 years
- About 75% of registered patients visits the GP in one year
o The average number of visits is 5; people often return (check-ups, prescriptions etc.)
o Elderly (>85 years) have an average number of 15
Most common reasons for GP visits in the Netherlands:
1. Hypertension
2. Urinary tract infections
3. Diabetes
4. Coughing
5. Fatigue
6. Acute upper airway infections
Age plays a role. Young children with infections, also elderly with diabetes and hypertension, causing changes in top 6
Causes of deaths top 10:
- Top global death causes associated with three broad topics:
o Cardiovascular; ischaemic heart disease, stroke
o Respiratory: chronic obstructive pulmonary disease, lower respiratory infections
o Neonatal conditions: birth asphyxia and birth trauma, neonatal sepsis and
infections, and preterm birth complications
- Causes of death grouped into three categories:
o Communicable; infectious and parasitic diseases and maternal, perinatal and nutritional conditions
o Noncommunicable; chronic
▪ 7 of top 10 causes were noncommunicable and also rising→44% of all deaths or 80% top 10
▪ All noncommunicable disease accounted in total for 74%
o Injuries
- Large variation depending on income in countries
o The top 10 is different for low-income countries; 6 diseases from the top 10 is communicable
Leading causes of death globally:
1. Ischaemic heart disease → increase
a. 1:6 deaths is caused by this: 16% of world’s total deaths
b. Largest increase in deaths; from 2 to 8.9 million deaths
2. Stroke
a. Caused 11% of total deaths
3. Chronic obstructive pulmonary disease
a. Caused 6% of total deaths
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, 4. Lower respiratory infections → decrease
a. Most deadly communicable disease
b. Numbers have gone down substantially; 460.000 less to 2.6 million
5. Neonatal conditions → decrease
a. One of the categories for which global deaths decrease has been greatest 1.2 million less to 2 million
6. Trachea, bronchus, lung cancers → increase
a. Risen from 1.2 to 1.8 million
7. Alzheimer’s disease and other dementias
a. Women disproportionately affected; 65% of deaths from Alzheimer’s and other types of dementia
8. Diarrhoeal diseases → decrease
a. Numbers from 2.6 million to 1.5 million
9. Diabetes mellitus → increase
a. Numbers are rising due to growing number of obesity
b. Increase in numbers with 70%
c. Responsible for the largest rise in male deaths; 80%
10. Kidney diseases → increase
a. Numbers are rising due to growing number of obesity
b. Numbers from 813.000 to 1.3 million
c. Related to age
HIV/AIDS used to be on the list, but these numbers have fallen by 51% during the last 20 years
Leading causes of death by income group:
- Low
o Neonatal conditions – lower respiratory infections – ischaemic heart disease – stroke – diarrhoeal
diseases – malaria – road injury – tuberculosis – HIV/AIDS – cirrhosis of the liver
o More likely to die from communicable disease; 6 out of 10
o Malaria, tuberculosis and HIV/AIDS in top 10; BUT significant decrease; 59% fewer deaths
o Diarrhoeal disease are decreasing; second biggest decrease in fatalities
o Deaths due to chronic obstructive pulmonary disease infrequent, doesn’t appear on top list for low-
income, but ranks in top 5 for all other income groups
- Low-middle
o Ischaemic heart disease – stroke – neonatal conditions – chronic obstructive pulmonary disease – lower
respiratory infections – diarrhoeal diseases – tuberculosis – cirrhosis of the liver – diabetes mellitus –
road injury
o Most disparate top 10; 5 noncommunicable, 4 communicable, 1 injury
o Diabetes is rising; nearly doubled since 2000
o Diarrhoeal disease remain a significant challenge, but biggest decrease from 1.9 to 1.1 million
o Biggest increase in ischaemic heart disease rising from 1 to 3.1 million
o HIV/AIDS has seen biggest decrease
- Upper-middle
o Ischaemic heart disease – stroke – chronic obstructive pulmonary disease – trachea, bronchus, lung
cancers – lower respiratory infections – diabetes mellitus – hypertensive heart disease – alzheimer’s
disease and other dementias – stomach cancer – road injury
o There has been an increase in lung cancer numbers; increase by 411.000
o High stomach cancer numbers in comparison to other income groups
o Biggest decrease for chronic obstructive pulmonary disease with 264.000 to 1.3 million
o Largest increase in ischaemic heart disease
o Only one communicable disease (lower respiratory infections)
- High
o Ischaemic heart disease – Alzheimer’s disease and other dementias – stroke – trachea, bronchus, lung
cancers – chronic obstructive pulmonary disease – lower respiratory infections – colon and rectum
cancers – kidney diseases – hypertensive heart disease – diabetes mellitus
o All deaths have been increasing, except two
▪ Hypertensive heart disease numbers are rising, reflecting a global trend
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, o Ischaemic heart disease and stroke have decreased by 16 and 21% → ONLY in the high income group
o Only has one communicable disease, which is respiratory infections
Disease trends can be partly explained by changes in demographics:
- Elderly is increasing (>85), young people decreases (<5)
Why assess how people die?
- Help assess effectiveness of health systems and direct resources to where they are needed most
- COVID-19 highlighted importance of countries to invest in civil registration and vital statistics system to allow
daily counting of deaths, and direct prevention and treatment efforts.
The diagnostic process:
Taking the anamnesis (GP):
- Duration and severity of symptoms; Localisation of pain, situation; Family
history, smoking, occupation; Medication; Past medical history
- ICE: ideas, concerns, expectations. Allow patient to tell story, without jumping in prematurely with questions
o Ideas: what do they think might be going on? Done any reading about symptoms or asked anyone?
o Concerns: Are they feeling anxious or worried about their symptoms? What is causing the concern?
Are there any particular areas where their symptoms might be making life difficult?
o Expectations: what are they hoping for from this consultation?
o → ICE needs to be addressed otherwise patients not happy. Need to feel heard; otherwise might not
tell everything. Try to convey empathy/concern, reinforcing that will do your best to help.
A structured approach to information-gathering in the medical history:
- Presenting complaints: why has the patient sought medical advice?
- History of the presenting complaints: further information about the patient’s main problem
- Past medical and surgical history
- Drug history and allergies
- Family history
- Social history: information on the patient’s present living arrangements and relevant risk factors
Physical examination (GP):
- Inspection; watching from the outside
- Auscultation; sounds, stethoscope, lung sounds, heart sounds etc.
- Percussion: important for abdomen to hear by tapping (hollow, firm etc.) to find what’s wrong
- Palpation: feeling. lump, soft or hard mass, only one mass or spread out over abdomen. Pain
The differential diagnosis:
- A list of possible diagnoses or disease that present similar signs or symptoms
Based on list of complaints and ruling out and the distance of differential diagnosis becomes
smaller. For patients it might be the other way around; think they have a terrible special disease
whilst it is a very common disease.
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, Further investigation (usually in hospital setting):
- Laboratory (Blood, urine)
- Tissue biopsy
- Spirometry (respiratory)
- ECG (cardiology)
- Imaging technology
SO: the diagnostic process in a scheme:
Step Examples
Anamnesis Duration of complaints, severity, smoking habits, occupation, medication use, living situation, height and weight
Examination
1 Inspection (use the eyes): is the patient pale or feverish, can you see discoloration of the skin, problems with posture, tremors
2 Auscultation (what can you hear): heart sounds, breathing sounds, gurgling sounds
3 Percussion (use your hands): tapping the abdomen or chest
4 Palpation (feel): feel for lumps, firmness, nodules
Investigation Imaging techniques, Blood sampling (e.g. glucose, blood lipids, inflammation markers), Urine sampling (e.g. glucose, protein,
infection) Spirometry (lung function)
Different types of imaging technology:
Depending on what the doctor needs to view will determine which type of medical imaging will be used.
Radiography (X-rays, CT-scans)
- Most common form of medical radiography imaging; X-rays
o Uses electromagnetic (ionizing) radiation
o Different structures
▪ Dense material or made of elements with high atomic number → collision, energy transfer
• Bones are dense and full of calcium which has a high atomic number, so absorbs the
X-rays well. Therefore it shows white on the X-ray
▪ Not dense material or elements with low atomic number → penetrate, no energy transfer
• X rays only transfer some energy and rest is scattered which leads to dark colour
• Soft tissue is not dense and contains lower atomic number elements like carbon,
hydrogen and oxygen, so more X-rays penetrate the tissue and darkens the film
o Small chance of causing mutations in reproductive organs and tissues e.g. thyroid (blocked by lead).
o Relatively inexpensive
o X-rays can be induced in two ways:
▪ High energy electrons in cathode tube hit metal component; get slowed down, release energy
▪ High energy electrons kicked off electrons from hit atoms, triggers reshuffling, releases energy.
- CT-scan (or CAT-scan) = computed tomography:
o Several high-resolution cross-sectional images are taken to create a more 3D view of the body parts
(position and shape) → tumours, blood clots, infections. It can also detect heart disease and cavities
o A CT scan works by sending a fan or cone of X-rays through a patient to an array of detectors. The X ray
beam is rotated around and down the patient, with the X-ray source tracing a spiral trajectory.
What is really going on; need to take X-ray view from all body angles to construct an internal image. With one X-ray
you can see density change due to solid tumour in patient, but if from multiple angles you can see position and shape
MRI (magnetic resonance imaging):
- Takes longer (30 minutes); not functional for everyone, due to the long time it takes
- More expensive than X-ray
- Uses magnets and radio waves to produce an image of the soft tissues: tumours, organ damage, brain
- No radiation; less risk than CT-scan
- High resolution images; can see brain inside the skull in comparison to the x-ray
o Do X-ray when interesting in a fracture on the skull, but MRI if you need to see inside of the brain
- Based on movement of protons in the body
- Consists of: Magnet, Radio waves, Gradient, Computer
- How does it work: The body is made of 70% water and water is magnetic. Water molecules consists
of an oxygen atom bonded to two hydrogen atoms (H2O). Small parts of the hydrogen atoms act
as tiny magnets. A big magnet is used to produce a unified magnetic field around the patient. The
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