Levenscyclus
Samenvatting GNK M1 blok 2 2022-2023
Inhoudsopgave
Urologie ......................................................................................................................................................... 6
Zwelling in het scrotum bij een kind ................................................................................................................... 6
Hydrocele ....................................................................................................................................................... 6
Varicocele ...................................................................................................................................................... 7
Cyste .............................................................................................................................................................. 7
Haematocele .................................................................................................................................................. 7
Inflammatie.................................................................................................................................................... 7
Tumor ............................................................................................................................................................ 7
Andere problemen in de lies en het scrotum bij een kind ................................................................................... 8
Cryptorchisme................................................................................................................................................ 8
Zwelling in de lies ........................................................................................................................................... 9
Voorhuidproblemen .......................................................................................................................................... 11
Vesico-urethrale reflux (VUR) ........................................................................................................................... 12
Andere urologische problemen (niet in leerdoelen) .......................................................................................... 13
Mictie ................................................................................................................................................................ 14
Plasproblemen .................................................................................................................................................. 16
Opslag gerelateerde lage urinewegsymptomen .......................................................................................... 16
Lozing-gerelateerde lage urinewegsymptomen .......................................................................................... 17
Diagnostiek plasproblemen ......................................................................................................................... 17
Behandeling plasproblemen ........................................................................................................................ 17
Urine-incontinentie ........................................................................................................................................... 18
Stressincontinentie ...................................................................................................................................... 18
Urge incontinentie ....................................................................................................................................... 18
Overloopincontinentie ................................................................................................................................. 19
Reflexincontinentie ...................................................................................................................................... 19
Blaasdysfunctie door bekkenbodemaanspanprobleem .............................................................................. 19
BPH, i.e. benigne prostaat hyperplasie ............................................................................................................. 20
Urineweginfecties ............................................................................................................................................. 21
Nierstenen en niersteenlijden ........................................................................................................................... 22
Nierstenen = urolithiasis .............................................................................................................................. 22
Niersteenlijden ............................................................................................................................................ 24
Hematurie ......................................................................................................................................................... 26
Niercelcarcinoom ......................................................................................................................................... 26
Urotheelcelcarcinoom ................................................................................................................................. 27
LUTS – lower urinary tract symptoms ............................................................................................................... 29
Dysfunctional voiding .................................................................................................................................. 29
Urethrastrictuur ........................................................................................................................................... 30
Prostaatcarcinoom....................................................................................................................................... 30
Flankpijn ........................................................................................................................................................... 30
Niersteenkoliek ............................................................................................................................................ 30
Pyelonefritis ................................................................................................................................................. 31
, Nier infarct ................................................................................................................................................... 31
Acute buik .................................................................................................................................................... 31
Afwijkingen van de glanspenis ......................................................................................................................... 32
Condylomata accuminata ............................................................................................................................ 32
Pearly penile papules (i.e. hirsuties papillaris penis) ................................................................................... 32
Infectieuze balanitis ..................................................................................................................................... 33
Herpes genitalis ........................................................................................................................................... 34
M. Zoon, i.e. Balanitis van zoon, i.e. balanitis plasmocellularis circumscripta ............................................ 35
M. Queyrat, i.e. erythroplasie van Queyrat ................................................................................................. 35
Gynaecologie ................................................................................................................................................ 38
SOA’s................................................................................................................................................................. 38
Gonorroe ..................................................................................................................................................... 38
Chlamydia trachomatis ................................................................................................................................ 39
Syphilis ......................................................................................................................................................... 40
Systemische consequenties van chlamydia en gonorroe ............................................................................ 41
Zwangerschapscomplicaties ........................................................................................................................ 41
Pelvic inflammatory disease (PID) .................................................................................................................... 41
Ectopische zwangerschap (EUG)....................................................................................................................... 42
Fysiologie menstruatie...................................................................................................................................... 44
Stadia van de vrouwelijke reproductieve gezondheid ................................................................................. 44
De HPG-as (Hypothalamic-Pituitary-Gonodal Axis) ..................................................................................... 45
De menstruele cyclus ................................................................................................................................... 45
De menstruatie ............................................................................................................................................ 46
Anticonceptie .................................................................................................................................................... 47
Combinatiepreparaten (oestrogeen en progesteron) ................................................................................. 47
Progesteron-only ......................................................................................................................................... 47
Non-hormonaal............................................................................................................................................ 47
DD Problemen met de menstruatie .................................................................................................................. 48
Cyclusstoornissen ........................................................................................................................................ 48
Primaire dysmenorroe ................................................................................................................................. 50
Secundaire dysmenorroe ............................................................................................................................. 50
Hevig menstrueel bloedverlies .................................................................................................................... 51
Onregelmatige cyclus................................................................................................................................... 51
DD Abnormaal vaginaal bloedverlies ............................................................................................................... 52
Uterus myomatosus..................................................................................................................................... 54
Adenomyosis uteri (endometriosis interna) ................................................................................................ 54
Endometriumpoliepen ................................................................................................................................. 55
Endometrium hyperplasie ........................................................................................................................... 55
Endometriumcarcinoom .............................................................................................................................. 56
DD Contactbloedingen ...................................................................................................................................... 56
Cervix ........................................................................................................................................................... 56
Vagina .......................................................................................................................................................... 57
Climacteriële klachten, i.e. overgangsklachten ................................................................................................ 58
Vaginale klachten ............................................................................................................................................. 60
Lichen Sclerosus ........................................................................................................................................... 60
Fluor vaginalis .............................................................................................................................................. 61
SOA .............................................................................................................................................................. 62
Vulvitis ......................................................................................................................................................... 62
Vaginitis ....................................................................................................................................................... 63
,Zwangerschap en Partus ............................................................................................................................... 65
Verloop zwangerschap ..................................................................................................................................... 65
Leefstijladviezen .......................................................................................................................................... 65
Prenatale screening ..................................................................................................................................... 65
Termijnbepaling ........................................................................................................................................... 66
Problemen zwangerschap................................................................................................................................. 66
Bloedverlies in het derde trimester uit de uterus........................................................................................ 66
Bloedverlies in het derde trimester uit de cervix ........................................................................................ 73
Bloedverlies uit andere plaatsen ................................................................................................................. 73
Hypertensie in de zwangerschap ...................................................................................................................... 73
Chronische hypertensie ............................................................................................................................... 73
Zwangerschapshypertensie ......................................................................................................................... 75
Partus ............................................................................................................................................................... 78
Anamnese en inspectie zwangere ............................................................................................................... 78
Palpatie – fundushoogte bepalen ................................................................................................................ 79
Palpatie – ligging foetus bepalen (handgrepen van Leopold) ...................................................................... 80
Foetale hartactie controleren ...................................................................................................................... 81
Obstetrisch toucher – POVIAS ..................................................................................................................... 83
Bepaling mate van indaling – vlakken van Hodge........................................................................................ 84
Ligging van het hoofd................................................................................................................................... 85
In partu verklaren ........................................................................................................................................ 85
Breken van de vliezen .................................................................................................................................. 86
Kunstfouten bij het begeleiden van de partus............................................................................................. 87
De baring van het kind ................................................................................................................................. 87
APGAR score bepalen .................................................................................................................................. 92
Afnavelen ..................................................................................................................................................... 92
Geboorte van de placenta ........................................................................................................................... 92
Postpartum controles .................................................................................................................................. 94
Video partus................................................................................................................................................. 95
Kraamperiode ................................................................................................................................................... 96
Koorts in het kraambed ............................................................................................................................... 96
Mastitis ........................................................................................................................................................ 97
Borstvoeding ..................................................................................................................................................... 98
Kunstvoeding .................................................................................................................................................. 105
Kindergeneeskunde .................................................................................................................................... 111
Acuut zieke zuigeling ...................................................................................................................................... 111
Symptomen acuut zieke zuigeling ............................................................................................................. 111
Alarmsymptomen bij een acuut ziek kind.................................................................................................. 111
DD koorts ................................................................................................................................................... 112
DD dyspneu ................................................................................................................................................ 112
DD sufheid ................................................................................................................................................. 113
DD vlekjes .................................................................................................................................................. 114
Herkennen ernstig ziek kind ...................................................................................................................... 115
Veelvoorkomende aanwijzingen/ clues die aandacht behoeven .............................................................. 115
Kinderlongziekten ........................................................................................................................................... 118
Alarmsymptomen bij kinderen met luchtwegklachten ............................................................................. 118
DD hoesten ................................................................................................................................................ 118
Acute bovenste luchtwegproblemen bij kinderen..................................................................................... 119
Acute onderste luchtwegproblemen bij kinderen ..................................................................................... 120
Chronische luchtwegproblemen bij kinderen ............................................................................................ 123
Vragen tijdens college................................................................................................................................ 125
, Hoesten – anamnese ................................................................................................................................. 126
Lichamelijk onderzoek bij kinderen met luchtwegproblemen .................................................................. 127
Mogelijke bevindingen bij lichamelijk onderzoek ...................................................................................... 128
Kind met pijn bij het plassen ........................................................................................................................... 130
DD pijn bij het plassen ............................................................................................................................... 130
Urineweginfectie ....................................................................................................................................... 130
Dysfunctional voiding ................................................................................................................................ 131
Vesico-urethrale reflux .............................................................................................................................. 131
Zindelijkheid .................................................................................................................................................... 131
DD enuresis nocturna ................................................................................................................................ 132
Kind met hoofdpijn ......................................................................................................................................... 134
DD hoofdpijn .............................................................................................................................................. 134
Alarmsymptomen hoofdpijn bij kinderen .................................................................................................. 134
Spanningshoofdpijn ................................................................................................................................... 134
Migraine ..................................................................................................................................................... 135
Medicatie-overgebruikshoofdpijn ............................................................................................................. 135
Clusterhoofdpijn ........................................................................................................................................ 136
Meningitis .................................................................................................................................................. 136
Hersentumor.............................................................................................................................................. 137
Kind met vermoeidheid ................................................................................................................................... 138
DD vermoeidheid ....................................................................................................................................... 138
Chronisch vermoeidheidssyndroom .......................................................................................................... 139
Beleid vermoeidheid zonder somatische oorzaak ..................................................................................... 140
Kind met buikpijn ............................................................................................................................................ 140
Alarmsymptomen anamnese ..................................................................................................................... 140
Alarmsymptomen lichamelijk onderzoek .................................................................................................. 141
DD acute buikpijn....................................................................................................................................... 141
DD chronische buikpijn .............................................................................................................................. 142
Functionele buikpijn .................................................................................................................................. 143
Obstipatie .................................................................................................................................................. 144
Coeliakie..................................................................................................................................................... 145
IBD – inflammatory bowel disease ............................................................................................................ 145
Lactose-intolerantie ................................................................................................................................... 147
Neonatale icterus............................................................................................................................................ 147
DD Neonatale icterus ................................................................................................................................. 147
Kernicterus ................................................................................................................................................. 148
Alarmsymptomen bij pathologische icterus .............................................................................................. 148
Diagnostiek icterus .................................................................................................................................... 149
Behandeling icterus ................................................................................................................................... 149
Spugende zuigeling ......................................................................................................................................... 149
Alarmsymptomen spugende zuigeling....................................................................................................... 149
DD spugen zuigeling................................................................................................................................... 149
Pylorushypertrofie ..................................................................................................................................... 150
Infectie ....................................................................................................................................................... 150
Gastro-oesofageale reflux.......................................................................................................................... 151
Overvoeding............................................................................................................................................... 152
Koemelkeiwitallergie ................................................................................................................................. 152
Kind met koorts............................................................................................................................................... 152
Alarmsymptomen bij een kind met koorts ................................................................................................ 152
Kind met vlekjes .............................................................................................................................................. 153
Alarmsymptomen bij een kind met vlekjes................................................................................................ 153
Meest voorkomende kinderziekten met vlekjes........................................................................................ 153
, DD kind met vlekjes ................................................................................................................................... 154
Kind met diarree ............................................................................................................................................. 154
Alarmerende symptomen en kenmerken .................................................................................................. 154
DD acute diarree ........................................................................................................................................ 155
DD aanhoudende diarree........................................................................................................................... 155
Dehydratie ................................................................................................................................................. 155
Beleid bij diarree ........................................................................................................................................ 156
Failure to thrive .............................................................................................................................................. 157
Inadequate intake ...................................................................................................................................... 157
Inadequate verwerking (malabsorptie) ..................................................................................................... 158
Verhoogd metabolisme ............................................................................................................................. 158
Hypoalbuminemie........................................................................................................................................... 159
DD hypoalbuminemie ................................................................................................................................ 159
Overig......................................................................................................................................................... 160
Sterilisatiewens ............................................................................................................................................... 160
Seksuologie ..................................................................................................................................................... 162
Zorg voor Migranten....................................................................................................................................... 165
Ethiek en Recht in de Kindergeneeskunde ...................................................................................................... 169
Belangrijke punten in de ontwikkeling van kinderen ...................................................................................... 172
Kindermishandeling ........................................................................................................................................ 173
Klinische Genetica ........................................................................................................................................... 177
Stamboom ................................................................................................................................................. 177
Verwijzen voor erfelijkheidsvragen of -onderzoek .................................................................................... 178
Overervingswijzen ..................................................................................................................................... 178
Dysmorfologie............................................................................................................................................ 180
4 verschillende risico formats in de oncogenetica..................................................................................... 181
4 verschillende manieren om risico’s uit te leggen ................................................................................... 181
Risicocommunicatie ................................................................................................................................... 181
Uitwerking leerdoelen en aantekeningen college ..................................................................................... 182
Quizvragen...................................................................................................................................................... 183
,Urologie
Zwelling in het scrotum bij een kind
DD:
- Hydrocele
- Varicocele
- Cyste
- Haematocele (vaak door trauma)
- Inflammatie
- Tumor
è Zwelling in de testis is een tumor, tot het tegendeel
bewezen is
Hydrocele
- Patente processus vaginalis, i.e. communicerende
hydrocele
= Scrotale zwelling door vocht in communicatie
scrotum en peritoneaal holte
o Presentatie: scrotale zwelling die
toeneemt gedurende de dag (wanneer
peritoneaal vocht ophoopt) en
afneemt in de nacht
o Wie: Kinderen tot 3 jaar, vaak na 1 jaar
vanzelf dicht
o Behandeling: chirurgische excisie
d.m.v. herniotomie, na 2 jarige leeftijd
(voor deze leeftijd herstelt het vaak
spontaan)
- Niet-communicerende hydrocele
= Scrotale zwelling door incomplete reabsorptie van vocht in de tunica vagnialis,
na sluiting processus vaginalis
o Presentatie: scrotale zwelling met transilluminatie en een voelbare testis
o Wie: meestal neonaten en kleine kinderen, verdwijnt vaak tussen 18 en 24
maanden
o Oorzaak:
§ Meestal primair; een scrotale zwelling, resulterend van incomplete
reabsorptie van vocht in de tunica vaginalis, na sluiting van de tunica
vaginalis
§ Soms secundair; als gevolg van testis trauma of torsi, epididymitis of
testis tumor
o LO: vocht-zwelling rondom een normale testis
§ Transilluminatie
§ Testis kan posterieur worden gevoeld
§ Vingers van de examinator kunnen boven de zwelling komen (i.e.
communiceert niet met de lies)
, o Echo: kan helpen bij diagnose
- Hydrocele elders
o Spermatic cord (hydrocele of the cord)
o Ronde ligament (ligamentum teres uterii) bij meisjes (hydrocele of the canal
of Nuck)
Varicocele
= spatader van het scrotum (opgezette ader naar de testis)
- 10% van de jongvolwassen mannen; 90% links
- Presentatie: meestal asymptomatisch; soms i.a.m. infertiliteit door
toename temperatuur van het scrotum.
- Diagnostiek: in staande patiënte, bij platliggen klappen de vaten in
en worden impalpabel.
- Behandeling: (alleen bij pijn/oligospermie) 1e keus is percutane
embolisatie; 2e keus is chirurgische ligatie.
Cyste
- Multiple cysten: ontwikkelen zich boven in de epididymis;
o Presentatie: pijnloze scrotale zwelling
- Epididymale cysten
o Transilluminaal; palpabele testis gescheiden van de cysten
o Jonge kinderen
- Spermatocele: enkele cyste met spermatozoa
o Vaak in hoofd van de epididymis (3e testis) / soms in spermatic cord
Haematocele
= scheur/bloeding van de testis door trauma
- Binnenin de testis = haematoom // open testis = haematocele
Inflammatie
- Epididymitis = inflammatie van de epididymis
- Orchitis = inflammatie testis, meestal bacterieel (SOA) / viraal
o Acuut: vaak viraal (mazelen) // Chronisch: door TBC of syphillitic gumma
Tumor
è Zwelling van/in de testis is een tumor, tot het tegendeel bewezen is
è 1,5% van alle mannelijke kankers; 30-40 jaar;
è Metastase naar intra-abdominale LK
- Kiemceltumoren (90%): snelgroeiend, agressief, intra-abdominale LK + longen
o Bij slecht-gedifferentieerde vorm, vaak verhoogd b-HCG (door
syncytiotrofoblast cellen)
- Seminomen (48%): uit spermatocyten; 20-45jr (piek 35jr)
o Bij gemetastaseerd seminoom >50% verhoogd LDH
o BH: orchidectomie, e.v.t. daarna radio- of chemotherapie
- Teratomen: uit multipotente stamcellen; piek 25jr
, o 75% van de gemetastaseerde teratomen verhoogd a-fetoproteïne (niet bij
seminoom) (door yolk-sac elementen)
o BH: orchidectomie, bij recidief chemo, LK-dissectie of surveillance
- Geslachtskoord/gonadale stromale tumoren
o Leydig cellen: uit gonadaal stroma, productie hormonen
o Sertoli cellen
o Mix
Andere problemen in de lies en het scrotum bij een kind
Cryptorchisme
= niet (goed) ingedaalde testis
- 3% van de a term pasgeborenen; 20% van de prematuren
- Volledige indaling meestal met 3-6 maand; 1,6% niet
- Normale afdaling:
o 1e fase: Migratie vanaf gonadale ridge naar interne inguinale
ring
§ Afhankelijk van verkorting gubernaculum, gedreven
door Müllerian inhibiting substance (MIS)
e
o 2 fase: Afdaling vanaf interne ring naar scrotum
§ Afhankelijk van androgenen
- Plaatsen: 20% in abdomen; 80% in liesgebied, inguinale kanaal, buiten de externe
ring (superficiale inguinale pouch) of bovenin scrotum; 1% ectopisch
o Tweede fase fout in de indaling vaak door structureel abnormale testis
- Houd rekening met mogelijk: intrekbare/retractiele testis (e.g. cremasterreflex/kou),
trauma, afwezige testis (mono-/anorchidisme) of verkeerde plaats van de testis.
- Risico’s:
o Maligniteiten
§ 10x hoger risico; zelf-examinatie is belangrijk; m.n. seminomen
o Subfertiliteit
§ Incomplete maturatie van de seminifereuze tubuli, leidend tot
afwijkende spermacellen + te hoge temperaturen (moet 1˚ lager
zijn).
o Torsie:
§ Abnormaal mobiele testis; meestal torsie van de spermatic cord,
leidend tot strangulatie en testiculaire necrose, en later atrofie.
o Cosmetische en psychologische impact
- Behandeling: zo vroeg mogelijk, tussen 6-12 maand;
o Orchidopexy: mobilisatie van de testis en spermatic cord
à processus vaginalis open à testis plaatsen in de
subcutane pouch.
o Laparoscopische Fowler-Stephens procedure bij
abdominale testis: testis mobiliseren door testiculaire
vaten door te nemen, 6 maanden later testis mobiliseren
aan de vas en naar het scrotum brengen.
Samenvatting GNK M1 blok 2 2022-2023
Inhoudsopgave
Urologie ......................................................................................................................................................... 6
Zwelling in het scrotum bij een kind ................................................................................................................... 6
Hydrocele ....................................................................................................................................................... 6
Varicocele ...................................................................................................................................................... 7
Cyste .............................................................................................................................................................. 7
Haematocele .................................................................................................................................................. 7
Inflammatie.................................................................................................................................................... 7
Tumor ............................................................................................................................................................ 7
Andere problemen in de lies en het scrotum bij een kind ................................................................................... 8
Cryptorchisme................................................................................................................................................ 8
Zwelling in de lies ........................................................................................................................................... 9
Voorhuidproblemen .......................................................................................................................................... 11
Vesico-urethrale reflux (VUR) ........................................................................................................................... 12
Andere urologische problemen (niet in leerdoelen) .......................................................................................... 13
Mictie ................................................................................................................................................................ 14
Plasproblemen .................................................................................................................................................. 16
Opslag gerelateerde lage urinewegsymptomen .......................................................................................... 16
Lozing-gerelateerde lage urinewegsymptomen .......................................................................................... 17
Diagnostiek plasproblemen ......................................................................................................................... 17
Behandeling plasproblemen ........................................................................................................................ 17
Urine-incontinentie ........................................................................................................................................... 18
Stressincontinentie ...................................................................................................................................... 18
Urge incontinentie ....................................................................................................................................... 18
Overloopincontinentie ................................................................................................................................. 19
Reflexincontinentie ...................................................................................................................................... 19
Blaasdysfunctie door bekkenbodemaanspanprobleem .............................................................................. 19
BPH, i.e. benigne prostaat hyperplasie ............................................................................................................. 20
Urineweginfecties ............................................................................................................................................. 21
Nierstenen en niersteenlijden ........................................................................................................................... 22
Nierstenen = urolithiasis .............................................................................................................................. 22
Niersteenlijden ............................................................................................................................................ 24
Hematurie ......................................................................................................................................................... 26
Niercelcarcinoom ......................................................................................................................................... 26
Urotheelcelcarcinoom ................................................................................................................................. 27
LUTS – lower urinary tract symptoms ............................................................................................................... 29
Dysfunctional voiding .................................................................................................................................. 29
Urethrastrictuur ........................................................................................................................................... 30
Prostaatcarcinoom....................................................................................................................................... 30
Flankpijn ........................................................................................................................................................... 30
Niersteenkoliek ............................................................................................................................................ 30
Pyelonefritis ................................................................................................................................................. 31
, Nier infarct ................................................................................................................................................... 31
Acute buik .................................................................................................................................................... 31
Afwijkingen van de glanspenis ......................................................................................................................... 32
Condylomata accuminata ............................................................................................................................ 32
Pearly penile papules (i.e. hirsuties papillaris penis) ................................................................................... 32
Infectieuze balanitis ..................................................................................................................................... 33
Herpes genitalis ........................................................................................................................................... 34
M. Zoon, i.e. Balanitis van zoon, i.e. balanitis plasmocellularis circumscripta ............................................ 35
M. Queyrat, i.e. erythroplasie van Queyrat ................................................................................................. 35
Gynaecologie ................................................................................................................................................ 38
SOA’s................................................................................................................................................................. 38
Gonorroe ..................................................................................................................................................... 38
Chlamydia trachomatis ................................................................................................................................ 39
Syphilis ......................................................................................................................................................... 40
Systemische consequenties van chlamydia en gonorroe ............................................................................ 41
Zwangerschapscomplicaties ........................................................................................................................ 41
Pelvic inflammatory disease (PID) .................................................................................................................... 41
Ectopische zwangerschap (EUG)....................................................................................................................... 42
Fysiologie menstruatie...................................................................................................................................... 44
Stadia van de vrouwelijke reproductieve gezondheid ................................................................................. 44
De HPG-as (Hypothalamic-Pituitary-Gonodal Axis) ..................................................................................... 45
De menstruele cyclus ................................................................................................................................... 45
De menstruatie ............................................................................................................................................ 46
Anticonceptie .................................................................................................................................................... 47
Combinatiepreparaten (oestrogeen en progesteron) ................................................................................. 47
Progesteron-only ......................................................................................................................................... 47
Non-hormonaal............................................................................................................................................ 47
DD Problemen met de menstruatie .................................................................................................................. 48
Cyclusstoornissen ........................................................................................................................................ 48
Primaire dysmenorroe ................................................................................................................................. 50
Secundaire dysmenorroe ............................................................................................................................. 50
Hevig menstrueel bloedverlies .................................................................................................................... 51
Onregelmatige cyclus................................................................................................................................... 51
DD Abnormaal vaginaal bloedverlies ............................................................................................................... 52
Uterus myomatosus..................................................................................................................................... 54
Adenomyosis uteri (endometriosis interna) ................................................................................................ 54
Endometriumpoliepen ................................................................................................................................. 55
Endometrium hyperplasie ........................................................................................................................... 55
Endometriumcarcinoom .............................................................................................................................. 56
DD Contactbloedingen ...................................................................................................................................... 56
Cervix ........................................................................................................................................................... 56
Vagina .......................................................................................................................................................... 57
Climacteriële klachten, i.e. overgangsklachten ................................................................................................ 58
Vaginale klachten ............................................................................................................................................. 60
Lichen Sclerosus ........................................................................................................................................... 60
Fluor vaginalis .............................................................................................................................................. 61
SOA .............................................................................................................................................................. 62
Vulvitis ......................................................................................................................................................... 62
Vaginitis ....................................................................................................................................................... 63
,Zwangerschap en Partus ............................................................................................................................... 65
Verloop zwangerschap ..................................................................................................................................... 65
Leefstijladviezen .......................................................................................................................................... 65
Prenatale screening ..................................................................................................................................... 65
Termijnbepaling ........................................................................................................................................... 66
Problemen zwangerschap................................................................................................................................. 66
Bloedverlies in het derde trimester uit de uterus........................................................................................ 66
Bloedverlies in het derde trimester uit de cervix ........................................................................................ 73
Bloedverlies uit andere plaatsen ................................................................................................................. 73
Hypertensie in de zwangerschap ...................................................................................................................... 73
Chronische hypertensie ............................................................................................................................... 73
Zwangerschapshypertensie ......................................................................................................................... 75
Partus ............................................................................................................................................................... 78
Anamnese en inspectie zwangere ............................................................................................................... 78
Palpatie – fundushoogte bepalen ................................................................................................................ 79
Palpatie – ligging foetus bepalen (handgrepen van Leopold) ...................................................................... 80
Foetale hartactie controleren ...................................................................................................................... 81
Obstetrisch toucher – POVIAS ..................................................................................................................... 83
Bepaling mate van indaling – vlakken van Hodge........................................................................................ 84
Ligging van het hoofd................................................................................................................................... 85
In partu verklaren ........................................................................................................................................ 85
Breken van de vliezen .................................................................................................................................. 86
Kunstfouten bij het begeleiden van de partus............................................................................................. 87
De baring van het kind ................................................................................................................................. 87
APGAR score bepalen .................................................................................................................................. 92
Afnavelen ..................................................................................................................................................... 92
Geboorte van de placenta ........................................................................................................................... 92
Postpartum controles .................................................................................................................................. 94
Video partus................................................................................................................................................. 95
Kraamperiode ................................................................................................................................................... 96
Koorts in het kraambed ............................................................................................................................... 96
Mastitis ........................................................................................................................................................ 97
Borstvoeding ..................................................................................................................................................... 98
Kunstvoeding .................................................................................................................................................. 105
Kindergeneeskunde .................................................................................................................................... 111
Acuut zieke zuigeling ...................................................................................................................................... 111
Symptomen acuut zieke zuigeling ............................................................................................................. 111
Alarmsymptomen bij een acuut ziek kind.................................................................................................. 111
DD koorts ................................................................................................................................................... 112
DD dyspneu ................................................................................................................................................ 112
DD sufheid ................................................................................................................................................. 113
DD vlekjes .................................................................................................................................................. 114
Herkennen ernstig ziek kind ...................................................................................................................... 115
Veelvoorkomende aanwijzingen/ clues die aandacht behoeven .............................................................. 115
Kinderlongziekten ........................................................................................................................................... 118
Alarmsymptomen bij kinderen met luchtwegklachten ............................................................................. 118
DD hoesten ................................................................................................................................................ 118
Acute bovenste luchtwegproblemen bij kinderen..................................................................................... 119
Acute onderste luchtwegproblemen bij kinderen ..................................................................................... 120
Chronische luchtwegproblemen bij kinderen ............................................................................................ 123
Vragen tijdens college................................................................................................................................ 125
, Hoesten – anamnese ................................................................................................................................. 126
Lichamelijk onderzoek bij kinderen met luchtwegproblemen .................................................................. 127
Mogelijke bevindingen bij lichamelijk onderzoek ...................................................................................... 128
Kind met pijn bij het plassen ........................................................................................................................... 130
DD pijn bij het plassen ............................................................................................................................... 130
Urineweginfectie ....................................................................................................................................... 130
Dysfunctional voiding ................................................................................................................................ 131
Vesico-urethrale reflux .............................................................................................................................. 131
Zindelijkheid .................................................................................................................................................... 131
DD enuresis nocturna ................................................................................................................................ 132
Kind met hoofdpijn ......................................................................................................................................... 134
DD hoofdpijn .............................................................................................................................................. 134
Alarmsymptomen hoofdpijn bij kinderen .................................................................................................. 134
Spanningshoofdpijn ................................................................................................................................... 134
Migraine ..................................................................................................................................................... 135
Medicatie-overgebruikshoofdpijn ............................................................................................................. 135
Clusterhoofdpijn ........................................................................................................................................ 136
Meningitis .................................................................................................................................................. 136
Hersentumor.............................................................................................................................................. 137
Kind met vermoeidheid ................................................................................................................................... 138
DD vermoeidheid ....................................................................................................................................... 138
Chronisch vermoeidheidssyndroom .......................................................................................................... 139
Beleid vermoeidheid zonder somatische oorzaak ..................................................................................... 140
Kind met buikpijn ............................................................................................................................................ 140
Alarmsymptomen anamnese ..................................................................................................................... 140
Alarmsymptomen lichamelijk onderzoek .................................................................................................. 141
DD acute buikpijn....................................................................................................................................... 141
DD chronische buikpijn .............................................................................................................................. 142
Functionele buikpijn .................................................................................................................................. 143
Obstipatie .................................................................................................................................................. 144
Coeliakie..................................................................................................................................................... 145
IBD – inflammatory bowel disease ............................................................................................................ 145
Lactose-intolerantie ................................................................................................................................... 147
Neonatale icterus............................................................................................................................................ 147
DD Neonatale icterus ................................................................................................................................. 147
Kernicterus ................................................................................................................................................. 148
Alarmsymptomen bij pathologische icterus .............................................................................................. 148
Diagnostiek icterus .................................................................................................................................... 149
Behandeling icterus ................................................................................................................................... 149
Spugende zuigeling ......................................................................................................................................... 149
Alarmsymptomen spugende zuigeling....................................................................................................... 149
DD spugen zuigeling................................................................................................................................... 149
Pylorushypertrofie ..................................................................................................................................... 150
Infectie ....................................................................................................................................................... 150
Gastro-oesofageale reflux.......................................................................................................................... 151
Overvoeding............................................................................................................................................... 152
Koemelkeiwitallergie ................................................................................................................................. 152
Kind met koorts............................................................................................................................................... 152
Alarmsymptomen bij een kind met koorts ................................................................................................ 152
Kind met vlekjes .............................................................................................................................................. 153
Alarmsymptomen bij een kind met vlekjes................................................................................................ 153
Meest voorkomende kinderziekten met vlekjes........................................................................................ 153
, DD kind met vlekjes ................................................................................................................................... 154
Kind met diarree ............................................................................................................................................. 154
Alarmerende symptomen en kenmerken .................................................................................................. 154
DD acute diarree ........................................................................................................................................ 155
DD aanhoudende diarree........................................................................................................................... 155
Dehydratie ................................................................................................................................................. 155
Beleid bij diarree ........................................................................................................................................ 156
Failure to thrive .............................................................................................................................................. 157
Inadequate intake ...................................................................................................................................... 157
Inadequate verwerking (malabsorptie) ..................................................................................................... 158
Verhoogd metabolisme ............................................................................................................................. 158
Hypoalbuminemie........................................................................................................................................... 159
DD hypoalbuminemie ................................................................................................................................ 159
Overig......................................................................................................................................................... 160
Sterilisatiewens ............................................................................................................................................... 160
Seksuologie ..................................................................................................................................................... 162
Zorg voor Migranten....................................................................................................................................... 165
Ethiek en Recht in de Kindergeneeskunde ...................................................................................................... 169
Belangrijke punten in de ontwikkeling van kinderen ...................................................................................... 172
Kindermishandeling ........................................................................................................................................ 173
Klinische Genetica ........................................................................................................................................... 177
Stamboom ................................................................................................................................................. 177
Verwijzen voor erfelijkheidsvragen of -onderzoek .................................................................................... 178
Overervingswijzen ..................................................................................................................................... 178
Dysmorfologie............................................................................................................................................ 180
4 verschillende risico formats in de oncogenetica..................................................................................... 181
4 verschillende manieren om risico’s uit te leggen ................................................................................... 181
Risicocommunicatie ................................................................................................................................... 181
Uitwerking leerdoelen en aantekeningen college ..................................................................................... 182
Quizvragen...................................................................................................................................................... 183
,Urologie
Zwelling in het scrotum bij een kind
DD:
- Hydrocele
- Varicocele
- Cyste
- Haematocele (vaak door trauma)
- Inflammatie
- Tumor
è Zwelling in de testis is een tumor, tot het tegendeel
bewezen is
Hydrocele
- Patente processus vaginalis, i.e. communicerende
hydrocele
= Scrotale zwelling door vocht in communicatie
scrotum en peritoneaal holte
o Presentatie: scrotale zwelling die
toeneemt gedurende de dag (wanneer
peritoneaal vocht ophoopt) en
afneemt in de nacht
o Wie: Kinderen tot 3 jaar, vaak na 1 jaar
vanzelf dicht
o Behandeling: chirurgische excisie
d.m.v. herniotomie, na 2 jarige leeftijd
(voor deze leeftijd herstelt het vaak
spontaan)
- Niet-communicerende hydrocele
= Scrotale zwelling door incomplete reabsorptie van vocht in de tunica vagnialis,
na sluiting processus vaginalis
o Presentatie: scrotale zwelling met transilluminatie en een voelbare testis
o Wie: meestal neonaten en kleine kinderen, verdwijnt vaak tussen 18 en 24
maanden
o Oorzaak:
§ Meestal primair; een scrotale zwelling, resulterend van incomplete
reabsorptie van vocht in de tunica vaginalis, na sluiting van de tunica
vaginalis
§ Soms secundair; als gevolg van testis trauma of torsi, epididymitis of
testis tumor
o LO: vocht-zwelling rondom een normale testis
§ Transilluminatie
§ Testis kan posterieur worden gevoeld
§ Vingers van de examinator kunnen boven de zwelling komen (i.e.
communiceert niet met de lies)
, o Echo: kan helpen bij diagnose
- Hydrocele elders
o Spermatic cord (hydrocele of the cord)
o Ronde ligament (ligamentum teres uterii) bij meisjes (hydrocele of the canal
of Nuck)
Varicocele
= spatader van het scrotum (opgezette ader naar de testis)
- 10% van de jongvolwassen mannen; 90% links
- Presentatie: meestal asymptomatisch; soms i.a.m. infertiliteit door
toename temperatuur van het scrotum.
- Diagnostiek: in staande patiënte, bij platliggen klappen de vaten in
en worden impalpabel.
- Behandeling: (alleen bij pijn/oligospermie) 1e keus is percutane
embolisatie; 2e keus is chirurgische ligatie.
Cyste
- Multiple cysten: ontwikkelen zich boven in de epididymis;
o Presentatie: pijnloze scrotale zwelling
- Epididymale cysten
o Transilluminaal; palpabele testis gescheiden van de cysten
o Jonge kinderen
- Spermatocele: enkele cyste met spermatozoa
o Vaak in hoofd van de epididymis (3e testis) / soms in spermatic cord
Haematocele
= scheur/bloeding van de testis door trauma
- Binnenin de testis = haematoom // open testis = haematocele
Inflammatie
- Epididymitis = inflammatie van de epididymis
- Orchitis = inflammatie testis, meestal bacterieel (SOA) / viraal
o Acuut: vaak viraal (mazelen) // Chronisch: door TBC of syphillitic gumma
Tumor
è Zwelling van/in de testis is een tumor, tot het tegendeel bewezen is
è 1,5% van alle mannelijke kankers; 30-40 jaar;
è Metastase naar intra-abdominale LK
- Kiemceltumoren (90%): snelgroeiend, agressief, intra-abdominale LK + longen
o Bij slecht-gedifferentieerde vorm, vaak verhoogd b-HCG (door
syncytiotrofoblast cellen)
- Seminomen (48%): uit spermatocyten; 20-45jr (piek 35jr)
o Bij gemetastaseerd seminoom >50% verhoogd LDH
o BH: orchidectomie, e.v.t. daarna radio- of chemotherapie
- Teratomen: uit multipotente stamcellen; piek 25jr
, o 75% van de gemetastaseerde teratomen verhoogd a-fetoproteïne (niet bij
seminoom) (door yolk-sac elementen)
o BH: orchidectomie, bij recidief chemo, LK-dissectie of surveillance
- Geslachtskoord/gonadale stromale tumoren
o Leydig cellen: uit gonadaal stroma, productie hormonen
o Sertoli cellen
o Mix
Andere problemen in de lies en het scrotum bij een kind
Cryptorchisme
= niet (goed) ingedaalde testis
- 3% van de a term pasgeborenen; 20% van de prematuren
- Volledige indaling meestal met 3-6 maand; 1,6% niet
- Normale afdaling:
o 1e fase: Migratie vanaf gonadale ridge naar interne inguinale
ring
§ Afhankelijk van verkorting gubernaculum, gedreven
door Müllerian inhibiting substance (MIS)
e
o 2 fase: Afdaling vanaf interne ring naar scrotum
§ Afhankelijk van androgenen
- Plaatsen: 20% in abdomen; 80% in liesgebied, inguinale kanaal, buiten de externe
ring (superficiale inguinale pouch) of bovenin scrotum; 1% ectopisch
o Tweede fase fout in de indaling vaak door structureel abnormale testis
- Houd rekening met mogelijk: intrekbare/retractiele testis (e.g. cremasterreflex/kou),
trauma, afwezige testis (mono-/anorchidisme) of verkeerde plaats van de testis.
- Risico’s:
o Maligniteiten
§ 10x hoger risico; zelf-examinatie is belangrijk; m.n. seminomen
o Subfertiliteit
§ Incomplete maturatie van de seminifereuze tubuli, leidend tot
afwijkende spermacellen + te hoge temperaturen (moet 1˚ lager
zijn).
o Torsie:
§ Abnormaal mobiele testis; meestal torsie van de spermatic cord,
leidend tot strangulatie en testiculaire necrose, en later atrofie.
o Cosmetische en psychologische impact
- Behandeling: zo vroeg mogelijk, tussen 6-12 maand;
o Orchidopexy: mobilisatie van de testis en spermatic cord
à processus vaginalis open à testis plaatsen in de
subcutane pouch.
o Laparoscopische Fowler-Stephens procedure bij
abdominale testis: testis mobiliseren door testiculaire
vaten door te nemen, 6 maanden later testis mobiliseren
aan de vas en naar het scrotum brengen.
