Klinisch eindexamen
CANMEDS LEERDOELEN
, Inhoud
Abdominale distensie.............................................................................................................................7
Abdominale/pelviene massa..................................................................................................................9
Hernia abdominale, inguinale...............................................................................................................11
Abdominale pijn in kinderen................................................................................................................12
Acute abdominale pijn..........................................................................................................................14
Chronische abdominale pijn.................................................................................................................19
Anorectale pijn.....................................................................................................................................21
Allergische reacties en atopie...............................................................................................................24
Aandacht-, leer- en schoolproblemen..................................................................................................25
Bloeding uit hoog gastro-intestinale tractus.........................................................................................27
Bloeding uit laag gastro-intestinale tractus..........................................................................................29
Bloed in sputum – hemoptysis.............................................................................................................32
Bloed in urine – hematurie...................................................................................................................34
Hypertensie..........................................................................................................................................36
Hypertensie in kinderen.......................................................................................................................38
Hypertensieve ziekten in de zwangerschap..........................................................................................39
Hypotensie, shock................................................................................................................................41
Borstmassa’s en opzettingen................................................................................................................43
Tepellekkage.........................................................................................................................................45
Brandwonden.......................................................................................................................................46
Hypocalcemie.......................................................................................................................................47
Hypercalcemie......................................................................................................................................48
Hartaanvallen.......................................................................................................................................50
Pijn op de borst....................................................................................................................................52
Bloedingen, blauwe plekken.................................................................................................................53
Preventie van veneuze trombose.........................................................................................................55
Constipatie...........................................................................................................................................56
Constipatie bij kinderen........................................................................................................................58
Contraceptie.........................................................................................................................................59
Hoest....................................................................................................................................................62
Cyanose, hypoxie..................................................................................................................................63
Antalgische gang bij kinderen...............................................................................................................65
Ontwikkelingsvertraging.......................................................................................................................66
1
, Volwassenen met ontwikkelingsbeperkingen......................................................................................68
Acute diarree........................................................................................................................................69
Chronische diarree...............................................................................................................................73
Pediatrische diarree..............................................................................................................................74
Diplopie = dubbelzien...........................................................................................................................76
Duizeligheid, vertigo.............................................................................................................................77
Stervende patiënt.................................................................................................................................79
Dysfagie................................................................................................................................................80
Dyspnoe................................................................................................................................................82
Pediatrische respiratoire distress.........................................................................................................84
Oorpijn..................................................................................................................................................88
Oedeem gegeneraliseerd.....................................................................................................................90
Oedeem gelokaliseerd..........................................................................................................................91
Rood oog..............................................................................................................................................94
Failure to thrive – kinderen..................................................................................................................96
Frailty bij ouderen................................................................................................................................98
Vallen....................................................................................................................................................99
Vermoeidheid.....................................................................................................................................101
Ataxie – gang......................................................................................................................................105
Congenitale abnormaliteiten, dysmorfie............................................................................................107
Glucose abnormaliteiten....................................................................................................................108
Diabetes mellitus................................................................................................................................110
Haar- en nagelafwijkingen..................................................................................................................118
Hoofdpijn............................................................................................................................................120
Gehoorverlies en doofheid.................................................................................................................124
Cerebrovasculair accident en transiënt ischemische aanval...............................................................127
Anemie...............................................................................................................................................128
Polycythemie, erythrocytose..............................................................................................................130
Taal- en spraakstoornissen.................................................................................................................131
pH afwijkingen....................................................................................................................................132
Infertiliteit..........................................................................................................................................134
Erectiele dysfunctie............................................................................................................................136
Incontinentie fecaal............................................................................................................................137
Incontinentie urinair...........................................................................................................................138
Incontinentie urinair bij kinderen, enuresis........................................................................................140
2
, Icterus.................................................................................................................................................141
Icterus bij de neonaat.........................................................................................................................142
Oligoarthralgie....................................................................................................................................143
Polyarthralgie.....................................................................................................................................146
Musculoskeletale pijn.........................................................................................................................149
Rugpijn en gerelateerde symptomen.................................................................................................150
Nekpijn...............................................................................................................................................153
Cholesterol- en lipidenstoornissen.....................................................................................................156
Afwijkende levertesten.......................................................................................................................157
Massa musculoskeletaal.....................................................................................................................159
Lymfadenopathie................................................................................................................................160
Mediastinale massa............................................................................................................................162
Menstruele cyclus stoornis - amenorroe, oligomenorroe..................................................................163
Dysmenorroe......................................................................................................................................165
Premenstrueel syndroom (PMS)........................................................................................................166
Menopauze.........................................................................................................................................167
Delirium..............................................................................................................................................169
Milde/ernstige neurocognitieve stoornis (dementie).........................................................................171
Coma..................................................................................................................................................172
Depressieve gemoedsstemming.........................................................................................................174
Manie/hypomanie..............................................................................................................................178
Bewegingsstoornis (onvrijwillig, tics, tremor).....................................................................................180
Hartgeruis, extra harttonen................................................................................................................182
Halsmassa, goiter, schildklieraandoeningen.......................................................................................183
Neonatale distress..............................................................................................................................185
Gevoelsstoornis, tintelingen...............................................................................................................187
Chronische diffuse pijn.......................................................................................................................189
Centraal – perifeer neuropathische pijn.............................................................................................192
Palpitaties...........................................................................................................................................195
Angst..................................................................................................................................................196
Pediatrische urgenties: acuut ziek kind..............................................................................................199
Huilend of geagiteerd kind.................................................................................................................202
Hypotone zuigeling.............................................................................................................................203
Pelviene pijn.......................................................................................................................................205
Preventief nazicht...............................................................................................................................207
3
, Evaluatie neonaat...............................................................................................................................210
Vaccinaties..........................................................................................................................................212
Preoperatieve evaluatie.....................................................................................................................214
Arbeidsgeneeskunde..........................................................................................................................216
Groei, ontwikkeling en gedrag van zuigeling, peuter, kind, adolescent..............................................219
Persoonlijkheidsstoornissen...............................................................................................................220
Pleura effusie......................................................................................................................................223
Intoxicatie...........................................................................................................................................225
Volksgezondheid - gezondheidsconcepten en determinanten...........................................................227
Meten en beoordelen van volksgezondheid......................................................................................229
Interventies op populatieniveau.........................................................................................................230
Gezondheidsprogramma’s op populatieniveau..................................................................................231
Outbreak management......................................................................................................................233
Omgevingsfactoren............................................................................................................................234
Gezondheid van bijzondere groepen..................................................................................................235
Hyperkaliëmie....................................................................................................................................236
Hypokaliëmie......................................................................................................................................237
Prenatale zorg....................................................................................................................................238
Bevalling en postnatale zorg...............................................................................................................240
Zwangerschapsonderbreking/spontane abortus................................................................................243
Preterme arbeid.................................................................................................................................244
Pelvische relaxatie, uterusprolaps......................................................................................................245
Proteïnurie..........................................................................................................................................246
Jeuk....................................................................................................................................................247
Psychose.............................................................................................................................................249
Acute nierinsufficiëntie, oligurie of anurie.........................................................................................252
Chronische nierinsufficiëntie..............................................................................................................254
Scrotale massa....................................................................................................................................255
Scrotale pijn........................................................................................................................................256
Clonieën – epilepsie............................................................................................................................257
Seksuele ontwikkeling........................................................................................................................259
Abnormale puberale ontwikkeling.....................................................................................................260
Seksuele bezorgdheden......................................................................................................................262
Huidulcera en tumoren......................................................................................................................263
Huiduitslag, papels.............................................................................................................................268
4
, Urticaria, angio-oedeem.....................................................................................................................273
Slaapstoornissen, slaapapnoe, insomnia............................................................................................274
Hyponatriëmie....................................................................................................................................277
Hypernatriëmie..................................................................................................................................278
Keelpijn en/of neusloop = rinorroe....................................................................................................279
Gestalte afwijkingen...........................................................................................................................281
Strabisme en/of amblyopie................................................................................................................283
Drug- en geneesmiddelen misbruik....................................................................................................284
Ontwenning........................................................................................................................................286
Wiegendood, sudden infant death syndrome (SIDS)..........................................................................287
Brief resolved unexplained event (= apparent life threatening event ALTE)......................................288
Suïcidaal gedrag..................................................................................................................................289
Syncope en presyncope......................................................................................................................292
Temperatuurafwijkingen, koorts en/of rillingen.................................................................................293
Koorts bij immuun-gecompromitteerde patiënt, recurrente koorts...................................................294
Hypothermie......................................................................................................................................295
Tinnitus...............................................................................................................................................296
Abdominaal trauma............................................................................................................................298
Beten en steken..................................................................................................................................299
Bot- en gewrichtstrauma....................................................................................................................300
Thoraxtrauma.....................................................................................................................................306
(bijna) Verdrinking..............................................................................................................................307
Aangezichtstrauma.............................................................................................................................308
Hand- en polstrauma..........................................................................................................................310
Schedeltrauma, hersendood, transplantdonatie................................................................................311
Zenuwtrauma.....................................................................................................................................317
Huidwonden.......................................................................................................................................319
Spinaaltrauma....................................................................................................................................321
Urinaire tractus trauma......................................................................................................................324
Vasculair trauma.................................................................................................................................325
Dysurie, urinaire frequentie en urgentie, pyurie................................................................................326
Polyurie en/of polydispie....................................................................................................................328
Lage urinaire tractus symptomen (LUTS)............................................................................................329
Vaginaal bloedverlies..........................................................................................................................331
Vaginaal verlies, jeuk, seksueel overdraagbare aandoeningen..........................................................333
5
, Kindermishandeling............................................................................................................................334
Ouderenmishandeling........................................................................................................................336
Mishandeling voor volwassenen/partnergeweld...............................................................................337
Visusstoornissen – acuut....................................................................................................................338
Visusstoornissen – chronisch..............................................................................................................340
Misselijkheid en braken......................................................................................................................342
Zwakte (niet gerelateerd aan CVA).....................................................................................................343
Gewichtstoename, overgewicht, obesitas..........................................................................................349
Gewichtsverlies, eetstoornis, anorexie...............................................................................................352
Intra-uteriene groeiretardatie (IUGR).................................................................................................354
Witte bloedcelafwijkingen..................................................................................................................355
Legale, ethische en organisatie aspecten van geneeskunde..............................................................357
Obsessieve-compulsieve en gerelateerde stoornissen.......................................................................358
6
, Abdominale distensie
Ascites
= vocht uit het vaatbed naar peritoneale ruimte
- Exsudaat: ↓serum/ascites albumine gradiënt (<11g/L)
o Peritoneale carcinomatose
- Transsudaat: ↑serum/ascites albumine gradiënt (>11g/L)
o Portale hypertensie - ↑sinusoïdale druk (vb. cirrose)
Vanaf 100cc opspoorbaar met echo (vnl flanken en kleine bekken), kliniek bij >2L
Diagnostische paracentese (30-40ml):
Heldergeel: sereus
Donker: belangrijke icterus
Troebel: infectie, maligniteit, pancreatische ascites (↑amylase)
Chyleus: maligne, onderbreking lymfebanen na abdominale heelkunde
Bloederig: traumatische punctie, HCC
Celtelling (<300-500 WBC/ml bij cirrose, PMN >250/ml bij spontane bacteriële
peritonitis), cytologie (maligne cellen)
Kweek
Behandeling bij cirrose: enkel voor patiënten-comfort, verbetering CV en respi functies,
vermindering risico SBP/hernia/hepatische hydrothorax
Creëren van een negatieve natriumbalans matige zoutbeperking + diuretica (1e
keuze spironolacton 1dd, evt. lisdiuretica toevoegen)
Paracentese: plasma-expansie om renale en circulatoire complicaties te voorkomen
(albumine bij >5L, synthetische plasma-expander bij <5L)
Peritoneoveneuze shunting (PVS): SC distaal intraperitoneaal naar proximal in v. cava
superior (+klep: unidirectioneel) – veel complicaties!!
Transjugulaire intrahepatische portosystemische shunt (TIPS)
Levertransplantatie
Darm dilatatie
- Mechanische obstructie = ileus obv obstructie van het darmlumen
o Adhesies: VG abdominale heelkunde
o Volvulus: deel van de darm is om zichzelf gedraaid met darmafsluiting tot gevolg
S/ Krampende buikpijn, nausea, (gal)braken, acuut abdomen, geen flatus,
geen stoelgang
Risicofactoren: intestinale malrotatie, Meckels diverticulum, Ziekte van
Hirschsprung, meconium ileus, obstipatie, abnormaal lang sigmoïd
Complicaties: necrose, perforatie
o Tumor, herniatie, galstenen, intussusceptie, IBD, fecale impactie
- Paralytisch ileus = ileus obv verminderde/afwezige peristaltiek
o Neuropathie bij DM
o Peritonitis (vb. bij immunotherapie)
o Pancreatitis
o Risicofactoren: abdominale chirurgie, opiaten, hypothyroïdie, hypoK
o Toxisch megacolon: complicatie van CU(/crohn), kan uitgelokt worden door hypoK,
anticholinergica, antidiarretica, colonvoorbereiding, luchtinsufflatie
Hypoperistalsis, plots zeer slecht, koorts, tachycardie, verminderd
bewustzijn, bloederige diarree risico op perforatie! (coloscopie = CI)
Rx: dwarse doorsnede >10cm, vochtopstapeling in atone darm
Inflammatie - ↑productie NO en paralyse glad spierweefsel – dilatatie colon
7
, R/ totale colectomie
- Lactose-intolerantie
o Lastasedeficiëntie - ↓lactose opname - ↑concentratie lactose in lumen darm –
bacteriële fermentatie – gasvorming en osmotische diarree (30-120min na ingestie)
o Kan secundair zijn aan: coeliakie, giardiasis, tropische spruw, bacteriële overgroei,
candidiasis
o Diagnose met eliminatie-provocatie test, waterstofademtest en zuurgraad feces
Andere
- Abdominale massa: zie volgende vraag
- Prikkelbare darmsyndroom = spastisch colon = irritable bowel syndroom (IBS)
o Oorzaak wss thv glad spierweefsel, intrinsieke of extrinsieke bezenuwing via n. vagus
o Verandering van de viscerale gevoeligheid + onbalans van neurotransmitters
o Abdo pijn, gestoorde defecatie: frequentie, vorm, drang; abdo distensie
o Rome III criteria: min 3d/m in afgelopen 3m abdo last/pijn: 2 van de 3:
Beterschap na defecatie
Opstoot gepaard gaande met verandering stoelgangsfrequentie
Opstoot gepaard gaande met verandering van stoelgangsvorm
Bijkomen: >3 def/d of <3 def/w, abnormale consistentie, abnormale passage,
slijmbijmenging, abdo opzetting of gasvorming
o R/ loperamide bij diarree, vezelrijke voeding en laxativa bij obstipatie,
antispasmodica (mebeverine) of anticholinergica (buscopan) bij abdominale pijn
- Organomegalie
o Hepatomegalie
Vb. In het kader van levermetastasen, leverstuwing bij hartfalen
(nootmuskaatlever), levercirrose, hepatitis, hemochromatose
- Pelviene massa: zie volgende vraag
o
8
, Abdominale/pelviene massa
Organomegalie
- Hepatomegalie
o Levermetastasen, leverstuwing bij rechter hartfalen (nootmuskaatlever), hepatitis,
toxoplasmose, platwormen – echinococcus cyste, hemochromatose, levercirrose
- Splenomegalie
o Salmonella gastro-enteritis, leverstuwing, malaria, Leishmania, Schistosomiasis,
levercirrose, hepatitis
- Vergrootte nieren
o Cysten
o Hydronefrose
Neoplasma
- Lymfoom/sarcoom
- GI-tumor
- Gynaecologische tumor
- Renaal/adrenale tumor
- Neuroblastoma
Gynaecologisch
- Ovarieel
o Benigne
Functioneel:
Follikelcyste: echo uniloculaire dunwandige cyste – RF = IUD –
conservatief beleid, echografische controle na 3m
Corpus-luteumcyste: echo dikwandige cyste, circumferentiële flow,
geen vascularisatie (DD solide tumor) – spontane resolutie 6-12w
Endometrioom: uniloculaire tumor met homogene echogene inhoud
Matuur teratoom (dermoïdcyste): uniloculair met gemengde echogeniciteit –
laparoscopische verwijdering (2% ontaard)
Sereus/mucineus cystadenoom: dunwandig uni/multiloculair (5-20cm) –
operatief verwijderen + vriescoupe perop
Benigne seks-cord stromale tumoren
o Maligne
Epitheliaal
In situ: gem 44j, 55% sereus, 40% mucineus, prognose 95%
o R/ laparotomie + cytologie op peritoneaal vocht (inoperabel
= aromatase-inhibitor) – follow-up echo + CA125
Invasief: gem 63j, RF ↑oestrogeen, BRCA1 (40%), BRCA2 (20%), Lynch
o R/ chirurgie + chemo – follow-up echo + CA125
Niet-epitheliaal:
Sex-cord stromale tumoren: granulosacel produceert oestrogeen –
endometriumhyperplasie/-carcinoom – inhibine B+, AMG+
o Hysterectomie + bil salpingo-oöforectomie
Kiemceltumoren: meest frequent mature teratomen - ↑gevoeligheid
voor chemo dus hoge kans op genezing
o Immatuur = maligne – unilaterale adnexectomie + chemo
Secundair: Krukenberg-tumoren: meta’s van borst- en GI-tumoren
merkers: CA125, CEA, alfafoetoproteïne, LDH, inhibine, AMH
9
CANMEDS LEERDOELEN
, Inhoud
Abdominale distensie.............................................................................................................................7
Abdominale/pelviene massa..................................................................................................................9
Hernia abdominale, inguinale...............................................................................................................11
Abdominale pijn in kinderen................................................................................................................12
Acute abdominale pijn..........................................................................................................................14
Chronische abdominale pijn.................................................................................................................19
Anorectale pijn.....................................................................................................................................21
Allergische reacties en atopie...............................................................................................................24
Aandacht-, leer- en schoolproblemen..................................................................................................25
Bloeding uit hoog gastro-intestinale tractus.........................................................................................27
Bloeding uit laag gastro-intestinale tractus..........................................................................................29
Bloed in sputum – hemoptysis.............................................................................................................32
Bloed in urine – hematurie...................................................................................................................34
Hypertensie..........................................................................................................................................36
Hypertensie in kinderen.......................................................................................................................38
Hypertensieve ziekten in de zwangerschap..........................................................................................39
Hypotensie, shock................................................................................................................................41
Borstmassa’s en opzettingen................................................................................................................43
Tepellekkage.........................................................................................................................................45
Brandwonden.......................................................................................................................................46
Hypocalcemie.......................................................................................................................................47
Hypercalcemie......................................................................................................................................48
Hartaanvallen.......................................................................................................................................50
Pijn op de borst....................................................................................................................................52
Bloedingen, blauwe plekken.................................................................................................................53
Preventie van veneuze trombose.........................................................................................................55
Constipatie...........................................................................................................................................56
Constipatie bij kinderen........................................................................................................................58
Contraceptie.........................................................................................................................................59
Hoest....................................................................................................................................................62
Cyanose, hypoxie..................................................................................................................................63
Antalgische gang bij kinderen...............................................................................................................65
Ontwikkelingsvertraging.......................................................................................................................66
1
, Volwassenen met ontwikkelingsbeperkingen......................................................................................68
Acute diarree........................................................................................................................................69
Chronische diarree...............................................................................................................................73
Pediatrische diarree..............................................................................................................................74
Diplopie = dubbelzien...........................................................................................................................76
Duizeligheid, vertigo.............................................................................................................................77
Stervende patiënt.................................................................................................................................79
Dysfagie................................................................................................................................................80
Dyspnoe................................................................................................................................................82
Pediatrische respiratoire distress.........................................................................................................84
Oorpijn..................................................................................................................................................88
Oedeem gegeneraliseerd.....................................................................................................................90
Oedeem gelokaliseerd..........................................................................................................................91
Rood oog..............................................................................................................................................94
Failure to thrive – kinderen..................................................................................................................96
Frailty bij ouderen................................................................................................................................98
Vallen....................................................................................................................................................99
Vermoeidheid.....................................................................................................................................101
Ataxie – gang......................................................................................................................................105
Congenitale abnormaliteiten, dysmorfie............................................................................................107
Glucose abnormaliteiten....................................................................................................................108
Diabetes mellitus................................................................................................................................110
Haar- en nagelafwijkingen..................................................................................................................118
Hoofdpijn............................................................................................................................................120
Gehoorverlies en doofheid.................................................................................................................124
Cerebrovasculair accident en transiënt ischemische aanval...............................................................127
Anemie...............................................................................................................................................128
Polycythemie, erythrocytose..............................................................................................................130
Taal- en spraakstoornissen.................................................................................................................131
pH afwijkingen....................................................................................................................................132
Infertiliteit..........................................................................................................................................134
Erectiele dysfunctie............................................................................................................................136
Incontinentie fecaal............................................................................................................................137
Incontinentie urinair...........................................................................................................................138
Incontinentie urinair bij kinderen, enuresis........................................................................................140
2
, Icterus.................................................................................................................................................141
Icterus bij de neonaat.........................................................................................................................142
Oligoarthralgie....................................................................................................................................143
Polyarthralgie.....................................................................................................................................146
Musculoskeletale pijn.........................................................................................................................149
Rugpijn en gerelateerde symptomen.................................................................................................150
Nekpijn...............................................................................................................................................153
Cholesterol- en lipidenstoornissen.....................................................................................................156
Afwijkende levertesten.......................................................................................................................157
Massa musculoskeletaal.....................................................................................................................159
Lymfadenopathie................................................................................................................................160
Mediastinale massa............................................................................................................................162
Menstruele cyclus stoornis - amenorroe, oligomenorroe..................................................................163
Dysmenorroe......................................................................................................................................165
Premenstrueel syndroom (PMS)........................................................................................................166
Menopauze.........................................................................................................................................167
Delirium..............................................................................................................................................169
Milde/ernstige neurocognitieve stoornis (dementie).........................................................................171
Coma..................................................................................................................................................172
Depressieve gemoedsstemming.........................................................................................................174
Manie/hypomanie..............................................................................................................................178
Bewegingsstoornis (onvrijwillig, tics, tremor).....................................................................................180
Hartgeruis, extra harttonen................................................................................................................182
Halsmassa, goiter, schildklieraandoeningen.......................................................................................183
Neonatale distress..............................................................................................................................185
Gevoelsstoornis, tintelingen...............................................................................................................187
Chronische diffuse pijn.......................................................................................................................189
Centraal – perifeer neuropathische pijn.............................................................................................192
Palpitaties...........................................................................................................................................195
Angst..................................................................................................................................................196
Pediatrische urgenties: acuut ziek kind..............................................................................................199
Huilend of geagiteerd kind.................................................................................................................202
Hypotone zuigeling.............................................................................................................................203
Pelviene pijn.......................................................................................................................................205
Preventief nazicht...............................................................................................................................207
3
, Evaluatie neonaat...............................................................................................................................210
Vaccinaties..........................................................................................................................................212
Preoperatieve evaluatie.....................................................................................................................214
Arbeidsgeneeskunde..........................................................................................................................216
Groei, ontwikkeling en gedrag van zuigeling, peuter, kind, adolescent..............................................219
Persoonlijkheidsstoornissen...............................................................................................................220
Pleura effusie......................................................................................................................................223
Intoxicatie...........................................................................................................................................225
Volksgezondheid - gezondheidsconcepten en determinanten...........................................................227
Meten en beoordelen van volksgezondheid......................................................................................229
Interventies op populatieniveau.........................................................................................................230
Gezondheidsprogramma’s op populatieniveau..................................................................................231
Outbreak management......................................................................................................................233
Omgevingsfactoren............................................................................................................................234
Gezondheid van bijzondere groepen..................................................................................................235
Hyperkaliëmie....................................................................................................................................236
Hypokaliëmie......................................................................................................................................237
Prenatale zorg....................................................................................................................................238
Bevalling en postnatale zorg...............................................................................................................240
Zwangerschapsonderbreking/spontane abortus................................................................................243
Preterme arbeid.................................................................................................................................244
Pelvische relaxatie, uterusprolaps......................................................................................................245
Proteïnurie..........................................................................................................................................246
Jeuk....................................................................................................................................................247
Psychose.............................................................................................................................................249
Acute nierinsufficiëntie, oligurie of anurie.........................................................................................252
Chronische nierinsufficiëntie..............................................................................................................254
Scrotale massa....................................................................................................................................255
Scrotale pijn........................................................................................................................................256
Clonieën – epilepsie............................................................................................................................257
Seksuele ontwikkeling........................................................................................................................259
Abnormale puberale ontwikkeling.....................................................................................................260
Seksuele bezorgdheden......................................................................................................................262
Huidulcera en tumoren......................................................................................................................263
Huiduitslag, papels.............................................................................................................................268
4
, Urticaria, angio-oedeem.....................................................................................................................273
Slaapstoornissen, slaapapnoe, insomnia............................................................................................274
Hyponatriëmie....................................................................................................................................277
Hypernatriëmie..................................................................................................................................278
Keelpijn en/of neusloop = rinorroe....................................................................................................279
Gestalte afwijkingen...........................................................................................................................281
Strabisme en/of amblyopie................................................................................................................283
Drug- en geneesmiddelen misbruik....................................................................................................284
Ontwenning........................................................................................................................................286
Wiegendood, sudden infant death syndrome (SIDS)..........................................................................287
Brief resolved unexplained event (= apparent life threatening event ALTE)......................................288
Suïcidaal gedrag..................................................................................................................................289
Syncope en presyncope......................................................................................................................292
Temperatuurafwijkingen, koorts en/of rillingen.................................................................................293
Koorts bij immuun-gecompromitteerde patiënt, recurrente koorts...................................................294
Hypothermie......................................................................................................................................295
Tinnitus...............................................................................................................................................296
Abdominaal trauma............................................................................................................................298
Beten en steken..................................................................................................................................299
Bot- en gewrichtstrauma....................................................................................................................300
Thoraxtrauma.....................................................................................................................................306
(bijna) Verdrinking..............................................................................................................................307
Aangezichtstrauma.............................................................................................................................308
Hand- en polstrauma..........................................................................................................................310
Schedeltrauma, hersendood, transplantdonatie................................................................................311
Zenuwtrauma.....................................................................................................................................317
Huidwonden.......................................................................................................................................319
Spinaaltrauma....................................................................................................................................321
Urinaire tractus trauma......................................................................................................................324
Vasculair trauma.................................................................................................................................325
Dysurie, urinaire frequentie en urgentie, pyurie................................................................................326
Polyurie en/of polydispie....................................................................................................................328
Lage urinaire tractus symptomen (LUTS)............................................................................................329
Vaginaal bloedverlies..........................................................................................................................331
Vaginaal verlies, jeuk, seksueel overdraagbare aandoeningen..........................................................333
5
, Kindermishandeling............................................................................................................................334
Ouderenmishandeling........................................................................................................................336
Mishandeling voor volwassenen/partnergeweld...............................................................................337
Visusstoornissen – acuut....................................................................................................................338
Visusstoornissen – chronisch..............................................................................................................340
Misselijkheid en braken......................................................................................................................342
Zwakte (niet gerelateerd aan CVA).....................................................................................................343
Gewichtstoename, overgewicht, obesitas..........................................................................................349
Gewichtsverlies, eetstoornis, anorexie...............................................................................................352
Intra-uteriene groeiretardatie (IUGR).................................................................................................354
Witte bloedcelafwijkingen..................................................................................................................355
Legale, ethische en organisatie aspecten van geneeskunde..............................................................357
Obsessieve-compulsieve en gerelateerde stoornissen.......................................................................358
6
, Abdominale distensie
Ascites
= vocht uit het vaatbed naar peritoneale ruimte
- Exsudaat: ↓serum/ascites albumine gradiënt (<11g/L)
o Peritoneale carcinomatose
- Transsudaat: ↑serum/ascites albumine gradiënt (>11g/L)
o Portale hypertensie - ↑sinusoïdale druk (vb. cirrose)
Vanaf 100cc opspoorbaar met echo (vnl flanken en kleine bekken), kliniek bij >2L
Diagnostische paracentese (30-40ml):
Heldergeel: sereus
Donker: belangrijke icterus
Troebel: infectie, maligniteit, pancreatische ascites (↑amylase)
Chyleus: maligne, onderbreking lymfebanen na abdominale heelkunde
Bloederig: traumatische punctie, HCC
Celtelling (<300-500 WBC/ml bij cirrose, PMN >250/ml bij spontane bacteriële
peritonitis), cytologie (maligne cellen)
Kweek
Behandeling bij cirrose: enkel voor patiënten-comfort, verbetering CV en respi functies,
vermindering risico SBP/hernia/hepatische hydrothorax
Creëren van een negatieve natriumbalans matige zoutbeperking + diuretica (1e
keuze spironolacton 1dd, evt. lisdiuretica toevoegen)
Paracentese: plasma-expansie om renale en circulatoire complicaties te voorkomen
(albumine bij >5L, synthetische plasma-expander bij <5L)
Peritoneoveneuze shunting (PVS): SC distaal intraperitoneaal naar proximal in v. cava
superior (+klep: unidirectioneel) – veel complicaties!!
Transjugulaire intrahepatische portosystemische shunt (TIPS)
Levertransplantatie
Darm dilatatie
- Mechanische obstructie = ileus obv obstructie van het darmlumen
o Adhesies: VG abdominale heelkunde
o Volvulus: deel van de darm is om zichzelf gedraaid met darmafsluiting tot gevolg
S/ Krampende buikpijn, nausea, (gal)braken, acuut abdomen, geen flatus,
geen stoelgang
Risicofactoren: intestinale malrotatie, Meckels diverticulum, Ziekte van
Hirschsprung, meconium ileus, obstipatie, abnormaal lang sigmoïd
Complicaties: necrose, perforatie
o Tumor, herniatie, galstenen, intussusceptie, IBD, fecale impactie
- Paralytisch ileus = ileus obv verminderde/afwezige peristaltiek
o Neuropathie bij DM
o Peritonitis (vb. bij immunotherapie)
o Pancreatitis
o Risicofactoren: abdominale chirurgie, opiaten, hypothyroïdie, hypoK
o Toxisch megacolon: complicatie van CU(/crohn), kan uitgelokt worden door hypoK,
anticholinergica, antidiarretica, colonvoorbereiding, luchtinsufflatie
Hypoperistalsis, plots zeer slecht, koorts, tachycardie, verminderd
bewustzijn, bloederige diarree risico op perforatie! (coloscopie = CI)
Rx: dwarse doorsnede >10cm, vochtopstapeling in atone darm
Inflammatie - ↑productie NO en paralyse glad spierweefsel – dilatatie colon
7
, R/ totale colectomie
- Lactose-intolerantie
o Lastasedeficiëntie - ↓lactose opname - ↑concentratie lactose in lumen darm –
bacteriële fermentatie – gasvorming en osmotische diarree (30-120min na ingestie)
o Kan secundair zijn aan: coeliakie, giardiasis, tropische spruw, bacteriële overgroei,
candidiasis
o Diagnose met eliminatie-provocatie test, waterstofademtest en zuurgraad feces
Andere
- Abdominale massa: zie volgende vraag
- Prikkelbare darmsyndroom = spastisch colon = irritable bowel syndroom (IBS)
o Oorzaak wss thv glad spierweefsel, intrinsieke of extrinsieke bezenuwing via n. vagus
o Verandering van de viscerale gevoeligheid + onbalans van neurotransmitters
o Abdo pijn, gestoorde defecatie: frequentie, vorm, drang; abdo distensie
o Rome III criteria: min 3d/m in afgelopen 3m abdo last/pijn: 2 van de 3:
Beterschap na defecatie
Opstoot gepaard gaande met verandering stoelgangsfrequentie
Opstoot gepaard gaande met verandering van stoelgangsvorm
Bijkomen: >3 def/d of <3 def/w, abnormale consistentie, abnormale passage,
slijmbijmenging, abdo opzetting of gasvorming
o R/ loperamide bij diarree, vezelrijke voeding en laxativa bij obstipatie,
antispasmodica (mebeverine) of anticholinergica (buscopan) bij abdominale pijn
- Organomegalie
o Hepatomegalie
Vb. In het kader van levermetastasen, leverstuwing bij hartfalen
(nootmuskaatlever), levercirrose, hepatitis, hemochromatose
- Pelviene massa: zie volgende vraag
o
8
, Abdominale/pelviene massa
Organomegalie
- Hepatomegalie
o Levermetastasen, leverstuwing bij rechter hartfalen (nootmuskaatlever), hepatitis,
toxoplasmose, platwormen – echinococcus cyste, hemochromatose, levercirrose
- Splenomegalie
o Salmonella gastro-enteritis, leverstuwing, malaria, Leishmania, Schistosomiasis,
levercirrose, hepatitis
- Vergrootte nieren
o Cysten
o Hydronefrose
Neoplasma
- Lymfoom/sarcoom
- GI-tumor
- Gynaecologische tumor
- Renaal/adrenale tumor
- Neuroblastoma
Gynaecologisch
- Ovarieel
o Benigne
Functioneel:
Follikelcyste: echo uniloculaire dunwandige cyste – RF = IUD –
conservatief beleid, echografische controle na 3m
Corpus-luteumcyste: echo dikwandige cyste, circumferentiële flow,
geen vascularisatie (DD solide tumor) – spontane resolutie 6-12w
Endometrioom: uniloculaire tumor met homogene echogene inhoud
Matuur teratoom (dermoïdcyste): uniloculair met gemengde echogeniciteit –
laparoscopische verwijdering (2% ontaard)
Sereus/mucineus cystadenoom: dunwandig uni/multiloculair (5-20cm) –
operatief verwijderen + vriescoupe perop
Benigne seks-cord stromale tumoren
o Maligne
Epitheliaal
In situ: gem 44j, 55% sereus, 40% mucineus, prognose 95%
o R/ laparotomie + cytologie op peritoneaal vocht (inoperabel
= aromatase-inhibitor) – follow-up echo + CA125
Invasief: gem 63j, RF ↑oestrogeen, BRCA1 (40%), BRCA2 (20%), Lynch
o R/ chirurgie + chemo – follow-up echo + CA125
Niet-epitheliaal:
Sex-cord stromale tumoren: granulosacel produceert oestrogeen –
endometriumhyperplasie/-carcinoom – inhibine B+, AMG+
o Hysterectomie + bil salpingo-oöforectomie
Kiemceltumoren: meest frequent mature teratomen - ↑gevoeligheid
voor chemo dus hoge kans op genezing
o Immatuur = maligne – unilaterale adnexectomie + chemo
Secundair: Krukenberg-tumoren: meta’s van borst- en GI-tumoren
merkers: CA125, CEA, alfafoetoproteïne, LDH, inhibine, AMH
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