Which glasses contact prescription represents legal blindness

100 cases of general medicine [3 ed.] 3437431587, 9783437431586

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100 cases of general medicine, 3rd EDITION

Reinhold Klein

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Imprint Elsevier GmbH, Hackerbrücke 6, 80335 Munich, Germany We look forward to your feedback and suggestions to ISBN 978-3-437-43158-6 ISBN e-book 978-3-437-09660-0 All rights reserved 3. new Revised edition 2019 © Elsevier GmbH, Germany Important notice for the user Doctors / practitioners and researchers must always rely on their own experience and knowledge when evaluating and using all information, methods, active substances or experiments described here. Due to the rapid increase in knowledge, particularly in the medical sciences, an independent review of diagnoses and drug dosages should be carried out. To the fullest extent of the law, Elsevier, the authors, editors, or contributors will not accept any liability for any personal injury or damage to property, product liability, negligence, or otherwise. This also applies to any application or operation of the methods, products, instructions or concepts listed in this work. The publisher assumes no liability for the completeness and selection of the drugs listed. Protected trade names (trademarks) are usually specially marked (®). However, the absence of such a reference cannot automatically lead to the conclusion that it is a free trade name. Bibliographic information from the German National Library The German National Library lists this publication in the German National Bibliography; detailed bibliographic data are available on the Internet at. 19 20 21 22 23 6 5 4 3 2 For copyright in relation to the images used, see. The work including all its parts is protected by copyright. Any use outside the narrow limits of copyright law without the consent of the publisher is inadmissible and punishable. This applies in particular to reproductions, translations, microfilming and storage and processing in electronic systems. In order not to disturb the flow of text, the grammatical masculine form was chosen for patients and job titles. Of course, all genders are always meant in these cases. Planning and concept: Inga Schickerling, Munich Project management and production: Alexander Gattnarzik, Munich Editing: Michaela Mohr / Michael Kraft, mimo-booxx | textwerk., Augsburg Typesetting: abavo GmbH, Buchloe Printing and binding: Drukarnia Dimograf, Sp.zoo, Bielsko -Biala, Poland Cover concept and design: Stefan Hilden, Munich, cover production: SpieszDesign, Neu-Ulm Title graphic: © Hildendesign using several motifs from ISBN Print 978-3-437-43158-6 ISBN e-Book 978-3-437- 09660-0 Current information can be found on the Internet at and

Preface Cases from general medicine - what is different from the other subjects? The “General Practice Cases” reflect the situation of the family doctor and his patients. The initial situation is completely different from that in the clinic - one of the reasons is. to the unselected patient. In contrast to the clinic and special practices, which mainly work after referral or instruction from colleagues and find patient items sorted by subject, in the general practice the door opens and the patient describes his complaints. In most cases there is a banality behind the complaints expressed. It is the task of the family doctor to identify the preventable, dangerous processes (AGVs) that may threaten the patient. The needs of the patient can hide both organic and psychological causes, which come from all medical specialties. Often several medical specialties are affected, this is particularly often the case with older, multimorbid patients. The patient does not bring a referral or referral slip on which diagnoses or key symptoms are already noted. Therefore, in this book, the cause of the consultation - usually represented by the patient's quoted "first sentence" - is the starting point for all subsequent steps. A detailed anamnesis in the classic sense is very rare in general medicine because of the limited time available. The family doctor can, however, rely on the "experienced anamnesis" for his long-term patients. For this reason, the anamnestics are usually targeted to the health problem presented by the patient, referred to in this book with the term "history". The history includes both specific anamnestics and experienced anamnesis. The same applies to the examination, it is also problem-oriented and targeted to the respective patient's concerns. In the general medical professional theory according to R. N. Braun, “diagnosis” means reliable disease detection. Such a scientifically proven diagnosis can be found in general practice in around 10% of cases. The general medical professional theory knows four classification areas: symptoms (approx. 25%), symptom groups (approx. 25%), clinical pictures (approx. 40%,) and diagnoses (approx. 10%). The daily routine of a general practitioner is therefore characterized by a lack of clarity. It is precisely the handling of this fuzziness that makes the family doctor so special. In the sea of ​​banalities, he has to “fish out” the rare, but highly threatening and avoidable dangerous processes and set the right course at an early stage. Specific strategies for this are to wait and see and to include the current state of evidence-based medicine - in particular the guidelines relevant to primary care and the bio-psycho-social overview. Everything under the premise that there is not enough time - doctor-patient contact usually only takes a few minutes. Egenburg, May 2019 Prof. Dr. Reinhold Klein, specialist in general medicine, sports medicine, chirotherapy, palliative medicine, lecturer at the Institute for General Medicine at the Technical University of Munich, Hauptstrasse 14, 85235 Egenburg

Acknowledgments I would like to thank Andrea and Henrik Friese, Amberg, for the support of the literature research, for the smooth handling of the paperwork and formatting to Ms. Heike Evers-Christophel, Egenburg, and Ms. Lena Fischer, Taxa. For the editorial support on the part of the publisher with Ms. Kathrin Nuehse, Ms. Inga Schickerling, Mr. Sebastian Bezold, Mr. Alexander Gattnarzik and Mr. Michael Kraft. For the review of the manuscript with Dr. med. Marianne Franke-Wirsching, Sixtnitgern, Prof. Dr. Renate Oberhoffer, Munich, Dr. med. Claudia Levin, Munich, Dr. med. Rainer Steinhardt, Dachau, Dr. med. Alexander Rieger, Munich, Dr. Peter Landendörfer, Heiligenstadt. Many thanks to all readers who have commented on this book - especially Ms. Britta Naujoks: Thank you for your constructive suggestions! Last but not least, I would like to thank my patients for allowing me to publish their medical history. Prof. Dr. Reinhold Klein

Proof of illustration The reference to the respective source of illustration can be found in square brackets at the end of the legend text in all illustrations in the work. All graphics and images not specially marked © Elsevier GmbH, Munich. E273

Mir A, Atlas of Clinical Diagnosis, 1st ed., 2003, 26683, Fig. 5.29


Patton K T, Thibodeau G A, Anatomy and Physiology, 1st ed., 2010, 55321 (Mosby)


Thomas P, Habif Clinical Dermatology, 4th ed., 2004, 13192


Klaue P, Checklist Small Surgery, 3rd edition, Thieme, 1990


Wind G G, Rich N M, Principles of Surgical Technique: Art of Surgery, Urban & Schwarzenberg, 1986


Susanne Adler, Lübeck


Stefan Dangl, Munich


Dr. Peter Banholter, Munich


Prof. Dr. Reinhold Klein, Egenburg


Gruber G, Hansch A, Kompaktatlas Blickdiagnosen in the internal medicine. Elsevier / Urban & Fischer, 2nd edition, 2009


Paulsen F, Waschke J, Sobotta. Atlas of Human Anatomy. Volume 1: General Anatomy and the Musculoskeletal System. Elsevier / Urban & Fischer, 24th edition, 2017


Prof. Dr. Andrea Baur-Melnyk


Clinic for Anaesthesiology, University Medicine of the Johannes Gutenberg University Mainz, Dr. Mathias Gerth


Abavo GmbH, Buchloe


Endres medical technology company

Abbreviations symbol γ-GT

Gamma GT

A A., Aa.

Artery (s)


ambulatory blood pressure monitoring


asymptomatic bacteriuria


Acrodermatitis chronica atrophicans


Angiotensin converting enzyme


Advanced Care Planning


general afebrile reaction


avertable dangerous course


alkaline phosphatase


External rotation


uncovered, realizable affections in need of treatment


acute rhinosinusitis


Achilles tendon reflex


incapacity for work


Alcohol Use Disorders Identification Test


Arterial Disease


apparatus-based behavioral therapy


General condition


Blood count


both sides, both sides


Consultation result


Trade association


Body mass index


benign prostatic hyperplasia


Sedimentation rate


Narcotics Prescription Regulation


Cause of consultation


Thoracic spine


Blood sugar





COPD assessment test


Centrum-Collum diaphysis


COPD Control Questionaire


Classification of Diverticular Disease


Carbohydrate-deficient transferrin


Creatine kinase

CO 2

Carbon dioxide


Chronic Obstructive Pulmonary Disease


Continuous Positive Airway Pressure


C-reactive protein


complex regional pain syndrome


chronic rhinosinusitis


Computed tomography

D d

Day / s


Dry bed training


Differential diagnosis


German Society for General Medicine and Family Medicine

d. H.

this means




Disease Management Program / s


Dual x-ray absorptiometry


evidence-based medicine


Epstein-Barr Virus




enterohaemorrhagic Escherichia coli




electrophysiological examination


Extended spectrum β-lactamase-producing gram-negative pathogens


Enzyme-linked Immunosorbent Assay




Nutritional status


familial adenomatous polyposis


forced one-second capacity




Early summer meningoencephalitis


forced vital capacity



Group A streptococci


Glasgow Coma Scale / Score


gastroesophageal reflux disease


glomerular filtration rate


Global Initiative for Obstructive Lung Disease


Glutamate oxaloacetate transaminase


Glutamate pyruvate transaminase


Glycopeptide-Resistant Enterococci


Glutamyl transferase



H h

Hour / n


Family doctor




Hepatitis B virus


human chorionic gonadotropin


Hydrochloric acid




High density lipoprotein


Heart rate


human granulocytic Ehrlichiosis


human herpes virus


Haemophilus influenzae


heparin-induced thrombocytopenia


hereditary non-polyposis colon cancer (Lynch syndrome)


human papillomavirus


Urinary tract infection


Instrumental Activities of Daily Living


Inhaled corticosteroids

i. d. R.



international units


German Infection Protection Act


Immunoglobulin G.


Internal rotation

i. v.


J J.

Year / s


coronary heart disease


Body surface


Carpal tunnel syndrome

L l



Long acting β 2 antagonist


Pulmonary artery embolism


Long Acting Muscarinic Antagonist


Lactate dehydrogenase


Low density lipoprotein


Pulmonary embolism


Year / s

Lumbar spine

Lumbar spine

M M., Mm.

Muscle, muscles


Manageable Geriatic Assessment


Munich alcoholism test


Monoamine oxidase


medical assistant


Minute / n

at least

at least


Measles, mumps, rubella


Modified Medical Research Council


Measles, mumps, rubella, and varicella


Mini Mental Status Test


Month / s


Magnetic resonance angiography


Medical Research Council


multi-resistant pathogens


Methicillin / multi-drug resistant Staphylococcus aureus


Magnetic resonance imaging


Millisecond / n


Morphine sulfate tablet / n

N N., Nn.

Nervus, Nervi


Sodium chloride


non-medical practice assistant




Sinus, Number Needed to Harm


Number Needed to Treat


new oral anticoagulants


nonsteroidal anti-inflammatory drugs


Non-ST-Segment Elevation Myocardial Infarction


new methods of examination and treatment


New York Heart Association





without (pathological) findings




Oxacillin-resistant Staphylococcus aureus


obstructive sleep apnea syndrome


Patient instructions for life support


peripheral arterial disease


percutaneous endoscopic gastrostomy



p. i.

by infusion

p. m.

post mortem

p. O.

per os, perorally




Proton pump inhibitor


prostate specific antigen


Patellar tendon reflex


partial thromboplastin time


relative afferent pupillary defect


Randomized Controlled Trial


Rattle / e


rapidly progressive glomerulonephritis


Riva-Rocci blood pressure, relative risk

S s

Second / n


Short acting β 2 antagonist


Short Acting Muscarinic Antagonist


specialized outpatient palliative care

s. c.





Status epilepticus




Status of generalized tonic-clonic seizures


Sacroiliac joint


so-called / r / s


Sinus rhythm


subacute sclerosing panencephalitis


Week of pregnancy


ST segment elevation myocardial infarction


Standing vaccination committee


Streptococcal Toxic Shock Syndrome


T3, T4

Triiodothyronine, thyroxine


transabdominal preperitoneal mesh implantation


Tablet / n


transesophageal echocardiography


transcutaneous electrical nerve stimulation


Total endoprosthesis


Every day


Transient ischemic attack


Thyroid stimulating hormone


toxic shock syndrome


deep vein thrombosis




Upper Airway Cough Syndrome


adverse drug effects


uncharacteristic fever cases


Lower leg

V V., Vv.

Vena, venae

v. a.


V. a.

suspicion of


Care assistant in the family doctor's practice


Atrial fibrillation


Vital capacity


Vancomycin-resistant enterococci


World Health Organization


Waist-to-hip ratio (waist-to-hip ratio)


Vertebral bodies


Week / n



Z z. A.

to the exclusion

Z. n.

State after

Laboratory values ​​name

Numerical value





g / dl



mmol / l

Total bilirubin


mg / dl


1st hour: 0-10, 2nd hour: 10-30




mg / dl



mmol / l


3900–10 300 (F) 4600–11 500 (M)

U / l


55 (F)> 45 (M)

mg / dl




Immunoglobulin G.


mg / dl





mmol / l

Calcium (total)


mmol / l



mmol / l


135-214 (F) 135-225 (M)

U / l

LDL cholesterol


mg / dl



Thousand / µl



U / l






g / dl






mmol / l

Pancreatic amylase


U / l

Procalcitonin quantitative


ng / ml

Gender dependent

Gender-independent information

Gender-independent information

No unity

Upper limit depending on gender


Numerical value











Serum creatinine

0.51-0.95 (F) 0.67-1.17 (M)

mg / dl



Thousand / µl

Transferrin saturation





mg / dl



µU / ml



U / l


Age and gender dependent


Headache "I'm coming to you because I've got a terrible headache again."

Prehistory The 41-year-old Ms. K.has been in the practice for years for frequent headaches and spinal problems. Patient data ▪ Known diagnoses: recurrent cervical and lumbar spine complaints; Arches on both sides; chronic pain; Propyphenazone allergy. ▪ Previous medication: Azur compositum (Paracetamol 350 mg; Caffeine 50 mg; Codeine 30 mg) has been taken for years. 1. What is a chronic headache? Which causes do you consider, which preventable dangerous processes (AGVs) have to be considered? 2. What questions do you ask the patient? 3. What diagnostic measures do you carry out or do you initiate? 4. Assess the patient's migraine therapy. What would you change about that? 5. Ms. K. complains of loss of libido, sleep disorders, nervousness and anxiety. How do you diagnose possible depression? 6. Which therapeutic measures can be considered for the treatment of depression in Ms. K.? How do you lead the patient?

1. Causes of chronic headaches By definition, chronic headaches are present if there is a headache for 15 days or more per month for 3 consecutive months (which lasts for at least 4 hours a day). Based on the IHS classification (Headache Classification Subcommittee of the International Headache Society), a distinction is made between 4 primary types of headache as the cause of a non-symptomatic chronic headache: ▪ IHS 1.5.1: chronic migraine ICD-10 G43.0 or G43.1 ▪ IHS 2.3: chronic tension-type headache ICD-10 G44.2 (often associated with pericranial pain sensitivity) ▪ IHS 4.7: hemicrania continua with a unilateral permanent headache ICD-10 G44.8 ▪ IHS 4.8: new permanent headache ICD-10 G44.2 (older classification - therefore same ICD as tension headache) In any case, headache due to drug overuse (ICD-10 G44.41), which is suspected in approx. 1–2% of the population, should also be considered. gives an overview of the criteria for the 4 types of chronic headache.

Tab. 1.1

Diagnostic criteria for the 4 types of chronic headache

Chronic migraine Migraine headache that occurs ≥ 15 days / month for ≥ 3 months without analgesic overuse A.

Headache that meets the criteria of migraine without aura on ≥ 15 days / month for> 3 months


Not due to any other illness

Episodic tension headache A.

At least 10 episodes that meet criteria B – D and an average of < 1="" tag/monat="">< 12="" tage/jahr)="">


The headache duration is between 30 minutes and 7 days


The headache has at least 2 of the following characteristics: ▪ Localization on both sides ▪ Pain quality pressing or constricting, not pulsating ▪ Mild to medium pain intensity ▪ No aggravation by routine physical activities such as walking or climbing stairs


Both of the following points are met: ▪ No nausea or vomiting (loss of appetite can occur) ▪ Either photophobia or phonophobia can be present, but not both


Not due to any other illness

Hemicrania continua A

Headache for> 3 months that meets criteria B – D


The pain has all of the following characteristics: ▪ One-sided headache without changing sides ▪ Daily and continuous, without pain-free intervals ▪ Medium intensity, but with exacerbations with severe pain


At least one of the autonomic symptoms listed below occurs on the pain side during exacerbations: ▪ Conjunctival injection and / or lacrimation ▪ Nasal congestion and / or rhinorrhea ▪ Miosis and / or ptosis


Reliable response to therapeutic doses of indomethacin


Not due to any other illness

New recurring headache A.

Headache that meets criteria B – D within 3 days of onset


The headache occurs daily and does not remit for> 3 months


The headache has at least 2 of the following characteristics: ▪ Localization on both sides ▪ Pressing or constricting, non-pulsating quality ▪ Mild to medium pain intensity ▪ No aggravation by routine physical activity such as walking or climbing stairs


Both of the following points are met: ▪ At most one is present: mild nausea or photophobia or phonophobia ▪ Neither moderate to severe nausea nor vomiting


Not due to any other illness

The episodic tension headache is the most common type of headache with a 90% lifetime prevalence. Other common causes of headache are migraines and cervical headache cases. The following also come into consideration: ▪ Refraction anomalies ▪ Sinusitis ▪ Hypertension and hypotension ▪ Cervical spine and eye problems due to computer work ▪ Sleep apnea syndrome ▪ Psychogenic / psychosocial causes (especially depression) ▪ Drug / drug related (alcohol, nicotine, coffee) ▪ Pseudotumor cerebri ▪ Oromandibular dysfunction (Teeth grinding - pain when chewing) The main things to be considered are: ▪ Intracerebral tumors ▪ Vascular anomalies (aneurysm) ▪ Glaucoma ▪ Meningitis ▪ Intracranial bleeding ▪ Sinus and cerebral vein thrombosis ▪ Temporal arteritis (ESR, CRP increased, risk of blindness)

▪ Cranio-cervical transition variant (pain when coughing, Valsalva) ▪ Metabolic (kidney, diabetes) Due to the history, an acute subarachnoid hemorrhage is ruled out, as its "trademark" is a sudden raging headache. Other acute causes are also out of the question, as the patient's complaints have been of constant quality for many years. Warning notices for AGVs: ▪ New headache with atypical character ▪ Atypical course (e.g. no improvement after the usual measures) ▪ Increasing pain intensity or changing pain character with known headaches ▪ Additional occurrence of neurological symptoms / failures ▪ After trauma ▪ Fever and meningism ▪ Unconsciousness ▪ Mental health problems ▪ New headaches after the age of 65

2. Questions to the patient In addition to the question of previous diagnostics and therapy as well as known diseases, the pain must be clarified in detail. The criteria for the 4 types of chronic headache are queried (). In addition, the focus is on possible preventable, dangerous processes and competing consulting results. The questions aim at the beginning (acute or creeping?), Localization, quality, intensity, duration, period, trigger and side effects. Most of the time, keeping a headache diary is helpful. ▪ Migraines, analgesic headaches, but also headaches with brain tumors often occur in the morning. ▪ Sinusitis has its maximum pain 1–2 hours after getting up, while tension headaches, trigeminal neuralgia and atypical facial pain usually occur during the day. ▪ Thunderclap headache, which occurs during orgasm, occurs as a sudden raging headache (cave: AGV subarachnoid hemorrhage). ▪ Localization and pain quality can provide important information. The patient's statements - one-sided, pulsating - make migraines likely. ▪ The pain intensity should e.g. B. can be queried using a pain scale (0 = no pain, 10 = unbearable pain). Highly painful diseases such as acute glaucoma, barosinusitis or intracerebral bleeding are hardly considered based on the patient's information. The moderate pain also suggests migraines. Migraine attacks occur repeatedly at irregular intervals or are triggered by certain events. As the trigger for the headache, Ms. K. stated the consumption of red wine - this would match the migraines that can be triggered by the consumption of tyramine-containing foods (red wine, cheese, chocolate). Eye flicker also goes with it. The accompanying symptoms in connection with the headache asked by the patient also help with the classification of the headache disorder. Ms. K. complains of gradual, moderate, one-sided and pulsating headaches as well as flickering scotomas and nausea in the morning. During the seizure, she feels the need to lie down in a darkened room. She only takes analgesics sporadically. Therefore, a migraine should be considered in the first place.

Note Typical occurrence of different types of headache during the day • At night: cluster headache • Morning: migraine, analgesic headache, brain tumor • During the day: tension headache, trigeminal neuralgia, atypical facial pain

3. Diagnostic measures As a rule, you will first measure your blood pressure and pulse, palpate the skull (including the temporal artery) and check the nerve exit points of the trigeminal nerve for tenderness and the temporomandibular joints for pressure sensitivity and function. In addition, the mobility of the cervical spine is checked and a possible paravertebral muscle tension in the area of ​​the cervical spine, thoracic spine and neck muscles is palpated. - Myogeloses can be the cause or consequence of headaches. A throat inspection as well as checking the sensitivity to tapping of the maxillary and frontal sinuses are also indicated. Checking the Unterberger stepping attempt or the blind gait with outstretched hands reveal any deviations in direction or a tremor of the hands. This examination is usually combined with the Romberg standing test. The examination of the pupils (round, isocorative, frontally reacting to light on both sides?) And the reflex status complement the examination. An otoscopy and an orienting examination of the eyesight (reading sample) should also be carried out. The psychological condition of the patient must also be assessed. In addition, a urine test (sugar / ketones), the determination of inflammation parameters (CRP / ESR) as well as a small blood count, creatinine and transaminases are indicated. If further diagnostics are planned, possibly with an iodine-containing injection of contrast medium, the TSH should also be determined. In all cases in which a partial cerebral mass or hemorrhage is a preventable, dangerous course, further diagnostics using imaging methods should be considered. For sudden headaches that appear for the first time after the age of 50, a CT scan without a contrast agent is currently the best examination method. It is quickly available and reliably reveals possible cerebral hemorrhages. In order to clarify chronic, worsening headaches, the MRI scan is better suited because of its greater sensitivity in the diagnosis of tumors, aneurysms and lesions of the posterior fossa. If necessary, a so-called magnetic resonance angiography (MRA) with vascular imaging is helpful to clarify vascular anomalies. Invasive procedures (angiography) have recently become less and less important. In the case of position-dependent headaches, a CSF puncture can be useful, if an epileptic event is in the room, an EEG should be performed. Results: Ms. K.'s physical examination and laboratory diagnostics did not reveal any abnormal findings. The patient received an MRI with MRA, which also showed no abnormalities. In this context, the questioning of the patient - as is so often the case - does not give a clear picture. Based on the anamnestic and findings, there are many arguments in favor of migraines. So you classify: image of migraine without aura (C).

4. Assessment of migraine therapy Before headache therapy is started, possible preventable and dangerous processes must be largely ruled out. Otherwise there is a risk

a concealment and procrastination of the case. If there is a high probability of a migraine, seizure therapy is sufficient for rare seizures and low pain medication consumption. In the case of our patient, a combination preparation consisting of paracetamol, codeine and caffeine was chosen. This does not exactly correspond to the recommendations of the Migraine Guideline. This recommends for acute therapy: ▪ Non-opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are effective in the treatment of migraines. ▪ Fixed combinations of paracetamol, ASA and caffeine are effective in acute migraine attacks. ▪ Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan and Zolmitriptan are the substances with the best effectiveness in acute migraine attacks, if they do not respond adequately to NSAIDs or zolmitriptan. B. address the above analgesics. They should be taken as early as possible in the attack. ▪ Ergotamine is effective against migraines (however, the effectiveness is poorly proven in prospective studies). ▪ Triptans are superior to ergot alkaloids (ergotamines) in terms of effectiveness. ▪ The combination of a triptan (especially sumatriptan) with an NSAID (especially naproxen) is superior to the respective monotherapy. ▪ Antiemetics - given about ½ hour before taking analgesics - are effective in treating nausea and vomiting and improve the absorption of painkillers. ▪ Opioids should not be used (useless). The effectiveness of non-drug methods in attack therapy has hardly been investigated in controlled studies. To ensure good absorption, metoclopramide (e.g. 1–2 tablets of 10 mg each) can be taken approx. 20–30 minutes before taking the tablet. In practice, non-opioid analgesics are usually used first. If this therapy fails, so-called triptans (see above) are possible. In addition to tablets, parenteral dosage forms are also available here (e.g. syringes for self-injection or nasal spray). These are only used when vomiting makes it impossible to take oral medication. Seizure prophylaxis: If there is a very high consumption of acute medication, especially painkillers, attacks usually last longer than 72 hours or if more than 3 attacks occur in a month with significant impairment of quality of life, permanent prophylaxis is indicated. The means of choice are: Migraine prophylactics of first choice are the beta blockers metoprolol and propranolol, the calcium antagonist flunarizine (cave: weight gain!) And the anticonvulsants topiramate and valproic acid (the latter not in patients of childbearing age without a safe method of contraception). ▪ Second choice migraine prophylactics are the beta blocker bisoprolol, the tricyclic amitriptyline, naproxen and acetylsalicylic acid. ▪ Erenumab: Recently there is a s. C. injectable monoclonal antibody for migraine prophylaxis. He is every 4 weeks. apply. The first study results are promising. Topiramate and onabotulinum toxin A are effective in chronic migraines with or without overuse of pain relievers or migraine drugs. If at all possible, drug treatment should be supplemented by behavioral therapy and aerobic endurance sports. So-called multimodal therapeutic approaches have been scientifically proven, which combine techniques of progressive muscle relaxation according to Jacobson, cognitive techniques as well as stimulus processing and stress management techniques, endurance sports and biofeedback (unfortunately the offer is still very limited).

Course Despite intensive efforts on the part of the family doctor, "the case always goes in circles". A clear diagnostic assignment is not possible, nor did one of the many therapeutic approaches for acute treatment or seizure prophylaxis achieve resounding success. Ms. K. has "already tried everything - nothing helped".

5. Diagnosis of depression Since Ms. K. also complains of a loss of libido, sleep disorders, nervousness and anxiety, a depressive illness should also be considered. In the family doctor's practice, two screening questions aimed at depression have proven effective: ▪ In the past month, have you often felt down, sad, depressed or hopeless? ▪ In the last month, have you had significantly less desire and enjoyment in things that you otherwise enjoy doing? If both questions are answered in the negative, pronounced depression can be ruled out with a high degree of certainty (sensitivity 96%). If one or both questions are answered with "yes", the clinical recording of the formal diagnostic criteria is required ().

Table 1.2

Major and minor symptoms of depression

Main symptoms ▪ Depressed, depressed mood ▪ Loss of interest, joylessness ▪ Lack of drive, increased fatigue Additional symptoms ▪ Decreased concentration and attention ▪ Decreased self-esteem and self-confidence ▪ Feelings of guilt and worthlessness ▪ Negative and pessimistic future prospects ▪ Suicidal thoughts / actions ▪ Sleep disorders ▪ Decreased appetite For diagnosis Depressive disorder according to ICD-10 should last at least 2 (in severe episodes 3) main symptoms for at least 2 weeks. Shorter periods can be considered if symptoms have become unusually severe or quick. In particularly severe cases, the diagnosis can be made earlier (< 2="" wochen)="" gestellt="" werden.="" man="" unterscheidet="" folgende="" formen:="" ▪="" leichte="" depressive="" episode="" (f32.0):="" mind.="" 2="" haupt-="" und="" 2="" nebensymptome="" ▪="" mittelgradige="" depressive="" episode="" (f32.1):="" mind.="" 2="" haupt-="" und="" 3–4="" nebensymptome="" ▪="" schwere="" depressive="" episode="" (f32.2;="" f32.3):="" mind.="" 3="" haupt-="" und="" ≥="" 4="" nebensymptome="" zur="" beurteilung="" des="" schweregrads="" einer="" „rezidivierenden="" depressiven="" störung“="" gelten="" zunächst="" dieselben="" kriterien="" wie="" bei="" der="" einzelnen="" depressiven="">

Somatic Syndrome Mild and moderate depression are often associated with a so-called "somatic syndrome", which, according to ICD-10, consists of the following symptoms

consists of: Main characteristics: ▪ Loss of interest or loss of enjoyment in normally pleasant activities. ▪ Inability to react emotionally to a friendly environment or happy events (affective vibrational ability). Secondary characteristics: ▪ Early morning awakening ▪ Low morning ▪ Objective finding of psychomotor inhibition or agitation ▪ Loss of appetite or Weight loss (often more than 5% of body weight in the past month) ▪ Loss of libido For the diagnosis of a somatic syndrome, at least 2 main and 2 secondary features or 1 main and 3 secondary features of the above should be considered Symptoms must be clearly identifiable. The most important question for the patient is the assessment of suicidality through direct addressing: "Have you ever thought about killing yourself?" Ms. K. says no. It indicates lack of interest, depressed mood, negative self-esteem and difficulty concentrating. Added to this are tiredness, increased urge to move and a loss of libido. All in all, she has moderate depression with somatic syndrome; further examinations may be necessary to rule out possible AGVs. The latter are extremely diverse and range from brain tumors, essential hypertension, alcoholism, carcinomas, anemia to drug-related causes (e.g. interferons, “pill”, Rauwolfia alkaloids, anti-Parkinson drugs). Here a sense of proportion is required, on the one hand, to not overlook anything important and, on the other hand, not to create an organic fixation through exaggerated diagnostics. Ideally, the doctor and patient should keep an eye on soma and psyche in equal measure during this phase. In the case of patient K. Laboratory tests of a general nature as well as a targeted examination for thyroid and sex hormones - without pathological findings.

6. Therapeutic measures Drug therapy In the case of mild or moderate depressive episodes, a first attempt at therapy can also be made with St. John's wort (dosage 900–1,350 mg extract / d) (cave: Quick increase in Marcumar® patients and impairment of the effect of hormonal contraceptives!). Possible side effects: photosensitization, allergic skin reactions, tiredness, rarely restlessness, sleep disorders and abdominal problems. In moderate cases, selective serotonin reuptake inhibitors (SSRIs) are the primary option, e. B. citalopram, fluoxetine or sertraline. This group of substances has few anticholinergic side effects and is safer than tricyclics if overdosed. Main side effects: restlessness, headache, nausea, prolonged bleeding time and tendency to perspire. Moclobemide (reversible MAO inhibitor) is far less dangerous than tranylcypromine, as there are only very few relevant interactions with food or other drugs. Moclobemide can cause restlessness and trouble sleeping. It is therefore not suitable for agitated depression, but has proven particularly useful in overweight patients, as it is more likely to lead to weight loss. Cave: no combination with opioids and serotonergic substances (malignant serotonin syndrome) or foods containing tyramine! In addition, selectively serotonergic and noradrenergic (SSNRI) agents are also in use, e.g. B. mirtazapine or venlafaxine. They rarely have anticholinergic side effects and occasionally lead to tiredness, increased appetite with weight gain (mirtazapine), leukopenia, edema (mirtazapine), nausea, agitation, increased blood pressure (venlafaxine) or insomnia and sweating. Classic tricyclic antidepressants: The classic tricyclics are still justified because of their good effect at a low price despite numerous side effects. However, they have a narrower therapeutic range, which is why regular level determinations should be made. First of all, you should primarily use SSRIs and, if necessary, SSNRIs, as these offer the least potential for interactions and side effects while at the same time offering a greater therapeutic range. Antidepressant therapy is administered for at least 6–12 months, then skip attempt. Ms. K. receives sertraline. Psychotherapy is being considered for a later date. Furthermore, depending on the expected side effects of the antidepressants used, control examinations, e.g. B. Laboratory, EKG (extended QT time) to perform.

Non-medicamentous measures Light therapy (30 min / d 10,000 lux “light shower”) can be very suitable, especially in the case of seasonal depression - always in autumn and winter. Partial sleep deprivation, which can be easily implemented on an outpatient basis and has a quick effect, has proven itself in practice. The patient is woken up at 1 a.m. and then stays awake all day until the evening. It is important that the patient does not “catch up” on sleep the next day. This procedure is repeated several times with an interval of 2-3 days. Sports activity such as B. jogging or cycling, as varied as possible with moderate stress, shows a rapid positive effect on depression. Psychotherapeutic procedures can be offered for acute mild and moderate depression. They are often combined with antidepressants. Combination therapy is mandatory for severe depression. In addition - if indicated - electroconvulsive therapy can be considered. Occupational therapy, sociotherapy and home psychiatric nursing are available as flanking measures. Patient guidance: Patients at risk of suicide must be contacted on a daily basis. Under certain circumstances, a “non-suicide contract” should be concluded with the patient. In this contract, the patient promises the doctor that he will not take any self-destructive measures until the next appointment and will report immediately in critical situations, and confirms this with his signature. If there is an acute risk of suicide, referral or referral are often unavoidable. Otherwise, at the latest one week after the start of therapy, if the drive increases, a follow-up should be made to clarify the suicidality and the tolerability of the drug. The patient should be informed that, unfortunately, no improvement can be expected after one week. As a result, the patient must be reassigned at appropriate intervals at fixed, agreed follow-up appointments. If possible, all therapy decisions are made in shared decision making.

Course After starting therapy, Ms. K. initially has problems; she complains of dizziness, tiredness, sleep disorders, sweating, constipation, cold feet and states of agitation (short-term prescription of a small pack of e.g. 1 mg lorazepam). After 4 weeks of improvement in my defensive attitude towards the husband, “the fear is gone.” After 4 months she says: “I only have occasional headaches, sometimes nightmares as well. My emotional life has improved a lot. I no longer have sexual problems. It's only this constant sweating that bothers me. ”After 6 months, the antidepressant is tapered off. The patient is generally satisfied with her treatment.

Note In the initial phase of therapy with antidepressants, frequent patient checks are very important! With increasing drive, the willingness to implement possible suicidal intentions may also increase.

Summary Headaches are a difficult problem in practice. On the one hand, dangerous processes such as brain tumors lurk, on the other hand, it is not easy for experts to differentiate between the various types of headache. In the treatment of migraines, a distinction is made between acute therapy and seizure prophylaxis. There is a wealth of therapy options for both areas. Depression sometimes appears as so-called masked depression in the form of physical complaints. Somatization and disorder

the vegetative functions are typical of the disease. The question of suicidality is a duty for the doctor. Under medical guidance, antidepressants are promising therapy options. Furthermore, psychotherapy, sleep deprivation, sport and, in the case of low-light depression, phototherapy can also be used. The patient must be closely monitored, especially at the beginning of therapy.


Bellyache "I come to you because my stomach hurts so much!"

Background The 52-year-old Ms. S. comes to the consultation on Friday: “I have terrible stomach ache again - just like 2 years ago!” Ms. S. looks sick, sweats, temperature 38.2 ° C rectally. During the examination you will find real bowel noises - pressure pain in the left lower abdomen with subtle defensive tension - no peritonitic stimulus during percussion. Patient data ▪ Known diagnoses: hypertension, polyarthrosis ▪ Previous medication: Ramipril 5 mg, HCT 12.5 mg 1. What cause of the abdominal pain do you suspect? 2. What examinations do you carry out in practice? 3. What do you look for in the ultrasound of the abdomen? Assess the sonogram ()




4. Outpatient or inpatient treatment - what criteria do you use to make the decision? 5. What therapeutic measures do you carry out in outpatient treatment? 6. What recommendations do you give the patient to avoid recurrences?

1. Causes The symptoms are relatively typical of diverticulitis. Two years ago, Ms. S. was therefore already inpatient in the internal department of the local clinic. Diseases of the female genitals (e.g. adnexitis), the urinary tract (cystitis, pyelitis, nephrolithiasis, etc.) come into question as competing consultation results. Other possible causes are colon carcinoma, ischemic colitis (unlikely in women of this age), irritable bowel syndrome, appendicitis (especially if the maximum pain cannot be precisely localized) and inflammatory bowel disease (Crohn's disease, ulcerative colitis), mesenteric infarction (more likely with older patients).

2. Examination in practice The following examinations are indicated: ▪ Palpation, percussion and auscultation of the abdomen ▪ Rectal examination ▪ Temperature measurement ▪ Laboratory (leukocytes, CRP and urine examination) ▪ Sonography Acute increasing pain in the left lower abdomen in connection with an increase in temperature> 7.6– 38 ° C, CRP> 5 mg / 100 ml, leukocytes> 10,000–12,000 / μl are typical symptoms of diverticulitis. The inflammation parameters develop i. d. Usually only for 1–2 days. One also speaks of a so-called left-sided appendicitis. Further symptoms: flatulence, spontaneous defecation, nausea, vomiting, constipation or diarrhea. The rectal examination may cause pain if the diverticulitis is deep. Closing the eyes during palpation (closed eye sign) is an indication of functional or psychosomatic complaints. Pollakiuria, dysuria, pneumaturia or even hematuria as well as pain in the genital area / dyspareunia indicate local complications (fistula, perforation in the bladder, irritation of the sacral plexus). If the clinical symptoms are appropriate, CRP values ​​of> 5 mg / 100 ml indicate diverticulitis, while a CRP value of> 20 mg / 100 ml suggests a perforation. At CRP concentrations of < 5="" mg/100="" ml="" ist="" in="" der="" folge="" eine="" perforation="" unwahrscheinlich.="" um="" einen="" abszedierenden/komplizierten="" verlauf="" auszuschließen,="" sollten="" in="" den="" ersten="" 48="" h="" nach="" beginn="" engmaschige="" kontrollen="" der="" subjektiven="" beschwerden="" sowie="" von="" abdominalbefund,="" temperatur,="" crp="" und="" leukozyten="">

3. Assessment of the sonogram On the one hand, the sonography searches for other causes of abdominal pain, such as B. ureter colic or pathologies of the adnexa.

On the other hand, she looks for sonographic signs of adnexitis: ▪ Hypoechoic, initially asymmetrical wall thickening (> 5 mm) with dissolution of the wall stratification, low deformability under pressure and a narrowing of the lumen ▪ Hypoechoic representation of the inflamed diverticulum, surrounded by an echogenic mesh cap (pericolic inflammatory fatty tissue reaction ) ▪ Hypoechoic inflammatory routes Furthermore, she has possible complications in her sights. Abscess formation speaks for hypoechoic or anechoic paracolic or intramural foci formation with echogenic reverberation echoes or "comet tail artifacts" caused by air reflexes. Air reflections within hypoechoic ribbon-like structures are characteristic of fistulas. Signs of a free perforation are evidence of free air and free, mixed echogenic liquid.

4. Type of treatment The procedure depends on the stage. The staging according to Hansen and Stock has been replaced in the new guideline by the Classification of Diverticular Disease (CDD). For general practice, this is of little importance, since a decision only has to be made about further outpatient or inpatient treatment - the clinic reserves the right to make further therapy decisions (e.g. surgical indication) using extensive diagnostics including CT, etc. Can be treated on an outpatient basis i. d. R. Stages Ia and Ib (identical in both classifications). That means cases without fever, leukocytosis, immune tension, palpable resistance, stool retention, evidence of perforation or complicated diverticulitis in the imaging. CRP should only be slightly increased and the general condition should be good. Risk factors (hypertension, chronic kidney disease, immunosuppression, allergic disposition) play an important role in the decision. Another prerequisite is sufficient oral food and fluid intake and close medical control. The inflammation parameters develop i. d. Usually only for 1 to 2 days, so that the 48-hour rule with clinical observation of the patient and laboratory checks (CRP) should be carried out over this period. Diverticular bleeding is also to be expected as a complication.

Note patients without fever, leukocytosis, immune tension, palpable resistance and stool retention can be treated on an outpatient basis. Perforation or complicated diverticulitis can be ruled out by imaging (Sono, CT). CRP should only be slightly increased and the general condition should be good.

5. Therapy measures in outpatient treatment The vast majority of patients with uncomplicated diverticulitis can be treated conservatively. Adequate hydration - if possible orally - must be ensured. If this is insufficient, parenteral hydration is indicated.

Antibiotics According to the guideline, antibiotic therapy can be dispensed with in acute, uncomplicated, left-sided diverticulitis without risk indicators under close clinical supervision. If there are risk indicators for a complicated course, antibiotics should definitely be given. Most colleagues will choose antibiotics for acute diverticulitis. As antibiotics for general practitioners, cefuroxime or ciprofloxacin combined with metronidazole and oral moxifloxacin are possible. Ampicillin / sulbactam would be available as a reserve drug, piperacillin / tazobactam must be administered via infusion, which in practice has its limits. If, despite adequate conservative treatment, the findings progress or the symptoms persist, an inpatient admission should be given.

Make sure to drink enough fluids! Cefuroxime or ciprofloxacin combined with metronidazole are suitable oral antibiotics.

6th RECOMMENDATION REGARDING THE R e c i d i v e s A general recommendation (diet, lifestyle, physical activity, medication) for conservative secondary prophylaxis of recurrent diverticulum disease cannot be given due to the insufficient data available according to the guideline. However, risk factors for diverticulitis should be largely eliminated. Here are a.o. The consumption of red meat, schnapps, insufficient fiber intake combined with increased fat consumption and smoking should be mentioned. NSAIDs, acetaminophen, and corticosteroids increase the risk of diverticular disease and bleeding. Opioids also promote diverticulitis, while calcium channel blockers increase the risk of bleeding. Cereals such as grains, nuts, maize / popcorn etc. do not seem to have any harmful influence, contrary to previous opinion.

Course Ms. S. is initially treated conservatively: She receives metronidazole and ciprofloxacin. In the course of the next 2 days, stomach pain and defensive tension increase and she has a fever: leukocytes 16,000, CRP 80 mg / dl. As a result, she is admitted to the hospital and a sigma resection is carried out. Since then she has been symptom-free in this regard.

Summary In terms of symptoms, diverticulitis appears as "left appendicitis". In the case of fever, leukocytosis, immune tension, palpable resistance, stool retention, evidence of perforation or complicated diverticulitis in the imaging or high or rising CRP, an inpatient admission should be made. Perforation and bleeding are to be expected as complications. In practice, even uncomplicated diverticulitis i. d. Usually antibiotic therapy, although the guideline does not necessarily provide for this.


Otitis media "I think my daughter has an otitis media again."

Background The 2½-year-old Tanja K. is brought to the practice by her mother: “I think Tanja has an otitis media again.Since the day before yesterday she has had a fever of up to 40 ° C, constantly grabs her left ear and whines. Please have a look. ”The ear inspection carried out shows a heavily reddened and bulging eardrum on the left (picture []). A week later, Ms. K. visits you again: “Tanja now has measles too!” Tanja now shows a clear rash. 1. Which AGV are threatened with otitis media? 2. Which diagnostics are indicated? 3. What therapeutic measures do you initiate? 4. When would you introduce the girl to the ear, nose and throat specialist? 5. What is the cause of the rash do you suspect? 6. How do you treat the rash?

1. AGVs The most common complications affect the ear itself. Intracranial complications are less common ().

Table 3.1

Complications and long-term damage in otitis media

Local (ear)


▪ Hearing impairment ▪ Vestibular damage ▪ Tympanic membrane perforation ▪ Otitis media chronica mesotympanalis ▪ Otitis media chronica epitympanalis (cholesteatoma) ▪ Mastoiditis () ▪ Facial nerve palsy

▪ Meningitis ▪ Encephalitis ▪ Epidural abscess, subdural empyema ▪ Brain abscess, hydrocephalus ▪ Sinus thrombosis

The eardrum is often perforated as part of otitis media. However, this closes i. d. Usually by itself and does not have to be tackled surgically. However, there is a risk of repeated otitis affecting both the eardrum and the ossicular chain

suffer permanent damage.

Fig 3.1

Swelling behind the ear: mastoiditis


2. Diagnosis In infancy, tragic pressure pain indicates otitis media; in older children and adults, this test tends to suggest otitis externa. In addition to the ear inspection (if necessary after careful cleaning of the auditory canal), it should be checked whether the mastoid is tender in order to detect the onset of mastoiditis in good time (preventable dangerous course!). Assessment of reddening of the eardrum, tympanic effusion, bulging or perforation. The facial nerve should also be checked. In order to rule out involvement of the organ of equilibrium, it is important to ensure an intact sense of balance or, in older children, the question of tinnitus or a tuning fork test may be helpful. Massive blood sedimentation increases or a very high CRP indicate a complication.

Note In otitis media, the following alarm signs point to a complication: • Massively increased ESR • Very high CRP • Mastoid painful to pressure

3. Therapeutic measures In any case, prescribe decongestant nasal drops and anti-inflammatory drugs: ▪ Paracetamol up to a maximum of 50 mg / kg body weight / day (corresponds to 10–15 mg / kg body weight / single dose, maximum 6 hours per day) ▪ Ibuprofen up to a maximum of 20 –30 mg / kg body weight / day (corresponds to 10 mg / kg body weight / single dose, max. 8 hours). Antibiotic therapy can i. d. As a rule, it should be waived within the first 48 hours after checking the findings. If the findings do not improve, antibiotic therapy is indicated, v. a. also to reduce the complication rate of acute otitis media. A good education is important here so that the parents can safely introduce themselves again in the event of deterioration. With regard to the course of the pain, there is no difference in uncomplicated cases with one or no administration of antibiotics. Skin rashes and diarrhea can often be avoided (). The complication rate is extremely low even without antibiosis.


Influence of antibiotics on pain in otitis media freedom from pain after 24 h

Freedom from pain after 2–7 d

Diarrhea, rash


62 %

85 %

17 %

Waiting open

62 %

79 %

11 %

Source: DEGAM guideline no. 7 ear pain

In contrast, in patients with an increased risk (younger than 24 months, concomitant / underlying illnesses, recent infections, immunosuppression, poor AZ due to high fever and persistent vomiting and / or diarrhea), antibiotics should be initiated immediately. Depending on the pathogens to be expected, the antibiotic of first choice is amoxicillin if there is no penicillin allergy. Macrolide antibiotics and cephalosporins can also be used. The DEGAM guideline recommends antibiotic treatment in uncomplicated cases after 48 hours as follows: ▪ 1st choice: Amoxicillin (e.g. Amoxi-Wolff®) 40–80 mg / kg body weight / day, 2–3 single doses above 7 days ▪ 2nd choice: Cephalosporin of group 2 (e.g. cefuroximaxetil 20–30 mg / kg body weight / day for 5 days) ▪ 3rd choice: If there are allergies to penicillin / cephalosporin: macrolides, e.g. B. Azithromycin (e.g. Zithromax®) 10 mg / kg body weight / day, over 3 days Depending on the course, the therapy should possibly be taken longer. If symptoms persist after the antibiotic therapy has ended, a follow-up visit to the practice is necessary.

Note the first choice antibiotic for otitis media: amoxicillin. Alternatively macrolides and cephalosporins.

4th H N O - P u r i tio n s In acute otitis media, paracentesis is not indicated. Nonetheless, therapy-resistant or recurrent otitis cases should be presented to the ENT doctor. After completing the treatment, a hearing test must be performed in any case. Tanja receives decongestant nose drops, paracetamol and amoxicillin juice. Because of the recurrences, a visit to the ENT doctor is planned.

5. Causes of the rash At first glance, the rash actually looks like measles (). It is a so-called "morbiliform exanthem". The girl does not show any catarrhal symptoms and has clear eyes. This appearance makes a connection with the antibiotics given 8 days ago highly probable. Especially with amoxicillin i. d. Typically morbiliform rashes without catarrhal symptoms occur approximately one week after the start of the drug administration. When amoxicillin is administered, such a rash must be expected in every 10th to 15th patient. Similar events are particularly common in the context of mononucleosis.

Fig 3.2



6. Treating the rash The amoxicillin rash is harmless. Apart from symptomatic measures for occasional itching, no therapy is required. The rash also disappears when the antibiotic is passed on. If possible, you will - for psychological reasons - stop taking it.


Otitis in young children is a common problem in practice. A thorough examination is necessary in every case because of the wide range of possible complications. In uncomplicated cases, symptomatic nasal spray and anti-inflammatory drugs can be used for the first 48 hours. The first choice antibiotic is amoxicillin. Maculopapular rashes occur in about 5–10% of cases after administration of amoxicillin. They are harmless and do not require therapy. If necessary, antibiotic therapy can still be continued.


Hyperthyroidism “I come to you because my goiter is growing. It won't be cancer, will it? "

History See hyperthyroidism. 56-year-old Ms. T. comes to the practice for a check-up because of her thyroid. Euthyroid goiter nodosa has been known for many years. Patient data Known diagnoses: ▪ Obesity grade II (BMI 39.9) ▪ Hypertension ▪ Lymphedema with rec. Erysipelas ▪ Bronchial asthma ▪ Paroxysmal atrial fibrillation ▪ Rheumatoid arthritis ▪ Diabetes mellitus type 2 Medication: ▪ Insulin Liprolog Mix (25 IU / ml) / lispro Isophan (75 U / ml): (26–28) 0–24 ▪ Candesartan 16 mg / HCT 12.5 mg: 1/0/0 ▪ Bisoprolol 2.5 mg: 1/0/0 ▪ Beclomethasone (100 µg) / Formoterol (6 µg) stroke: 1/0/1 ▪ Rivaroxaban 20 mg: 0/0 / 1 ▪ Metfomin 1000 / Sitagliptin 50: 1/0/1 Anamnestics Ms. T. has been feeling nervous and agitated lately. She noted that “the goiter has grown. It won't be cancer after all, because cancer is at home in my family ”(sister and mother Mamma-Ca, grandmother Colon-Ca). A blood sample and thyroid ultrasound (,) will be arranged.


Thyroid Sonography



Ms. T.


Measured value

Normal value


120 mg / dl

70-100 mg / dl

HbA 1c

8,4 %

5,7–6,4 %

fT 3

4.2 pg / ml

1.64-3.45 pg / ml

fT 4

2.3 ng / dl

0.71-1.85 ng / dL


< 0,1="">

0.3-4.0 mU / l


0.81 mg / dl

0.8-1.2 mg / dl

Micral test (urine tests for albumin)



1. What does sonography tell you about lumps in the thyroid gland? Assess the sonogram (2. what symptoms do you ask the patient - what do you pay attention to during the examination? 3. What further examinations do you arrange? 4. What treatment options are there? What advice do you give the patient? 5. One week after the operation Ms. T. complains of tingling in her arms and legs. What do you suspect? How do you proceed? 6. What therapy do you carry out?

1. Assessment of sonogram sonographic findings: multiple nodular remodeling, partly halonised, partly central cystic part; Knots up to 2 cm in diameter. Volume 15.5 ml on the left, 3.8 ml on the right, total volume 19 ml. The importance of SD sonography lies in the selection of "suspicious malignancy" nodes that require further clarification (fine needle biopsy, if necessary histology). Echo-free nodules are benign serous cysts or colloid cysts. Internal echoes in cystic structures occur with hemorrhage, but malignancies can also present themselves as a result of necrotic decay. Echo-like halonized or echo-dense nodes are mostly macrofollicular adenomas. Hypoechoic nodules represent the biggest problem with regard to the assessment of the dignity: small cystic degenerated nodules, microfollicular (also autonomous) adenomas, parathyroid adenomas, iron-hard Riedel's goiter and nodules after radioiodine therapy belong to this group, as do most thyroid carcinomas. Sonographic malignancy criteria: ▪ Solid hypoechoic nodule ▪ Microcalcifications ▪ Intranodular vascularization pattern (color-coded duplex sonography) ▪ Fuzzy margins ▪ Anterior-posterior diameter larger than transversal. If several suspicious ultrasound findings are detected in one SD node, the sensitivity is 83–99% and the specificity 56–85% for the presence of an SD malignancy. Scintigraphy helps insofar as scintigraphically cold nodules are more likely to be suspicious of malignancy. Another diagnostic option is elastography. The multinodular goiter represents a particular challenge in the assessment of the dignity, in which the combination of ultrasound and scintigraphy findings must be used to focus on non-autonomous and cold areas with sonographically conspicuous findings. Since the TSH is low, the metabolism is hyperthyroid. A relative therapy indication exists, depending on the symptoms, from a TSH basal value of 0.1–0.45 µU / ml, for values < 0,1="" µu/ml="" eine="" absolute="" therapieindikation.="" bei="" hypothyreosen="" besteht="" ab="" tsh=""> 10 µU / ml an absolute, from 4.5 µU / ml a relative indication for treatment.

2. Symptoms of the patient You are looking for signs of hyperthyroidism. History: ▪ Hyperactivity ▪ Palpitations ▪ Heat intolerance ▪ Increased sweating ▪ Weight loss ▪ Increased stool frequency ▪ Oligomenorrhea or amenorrhea ▪ Gynecomastia and erectile dysfunction ▪ Myopathy of the proximal shoulder and pelvic girdle muscles ▪ Concentration disorders ▪ Reduced short-term memory up to : ▪ Fine finger tremor ▪ Hyperreflexia ▪ Upper eyelid retraction ▪ Tachycardia, possibly atrial fibrillation ▪ Onycholysis, drumstick fingers in long-term hyperthyroidism

Note Many typical symptoms of hyperthyroidism can be explained by an increased sympathetic tone.

3. FURTHER INSPECTION In any case, a thyroid scintigraphy with technetium should be arranged to exclude or verify an autonomous adenoma. It also helps with the assessment of dignity. If necessary, a determination of the SD antibodies TRAK (TSH-like antibodies, usually increased in Graves disease) and TPO-AK (thyroid peroxidase antibodies, usually increased in Hashimoto's thyroiditis) is useful. If necessary, the thyroglobulin can be determined in order to search for a - overall rather rare - medullary SD carcinoma.

Findings by scintigraphy show left-sided autonomy with increasing Tc uptake in the course of the disease ().


Thyroid scintigraphy


The SD antibodies TRAK and TPO are negative.

4. Therapy options Therapeutically, radioiodine therapy is an option for Ms. T., alternatively a thyroid resection. In contrast to Graves' disease, thyrostatic treatment is not promising in this case from a curative point of view and may be considered in the case of old age and / or multimorbidity. Beta-blocker therapy, which may be indicated for intermittent symptom control, is not necessary, as Ms. T. is already taking bisoprolol because of her hypertension. Since the thyroid gland is growing, the morphological situation is very confusing and Ms. T. is afraid of cancer, the doctor and patient decide together for an operation. The thyroid function must be normalized preoperatively with medication. You should also see an ENT doctor in order to rule out any pre-operative damage to the vocal cords (risk of damage to the recurrent laryngeal nerve from the operation).

Course Intraoperatively, the colleagues decide on a total SD resection on both sides. The histology shows goiter colloides nodosa and adenomatosa on both sides, no evidence of malignancy.

5. Cause of the tingling sensation Since the thyroid gland has been completely removed, which of course does not leave the epithelial cells unscathed, the suspicion of hypocalcemia is obvious. This is confirmed in the laboratory: approx. 1.4 mmol / l (standard 2.2–2.6 mmol / l). You write an EKG. ECG results: F = 75 / min., Sinus rhythm left position 0.13 s, QRS = 0.16 s, QT = 0.40 s, RsR V1 – V3, T negativity V1 – V3. Assessment: complete right bundle branch block. Given the hypocalcemia, one would have expected QT prolongation. The measured QT time is approx. 15% above the norm, but this is also due to the QRS widening as a result of the right bundle branch block. Definite signs of hypocalcaemia cannot be read from this ECG.

6. Hypocalcemia therapy A substitution therapy from a value of < 1,8="" mmol/l="" soll="" notfallmäßig="" i.="" v.="" erfolgen="" mit="" einer="" infusion="" über="" 24="" stunden.="" daher="" wird="" die="" patientin="" ins="" krankenhaus="" eingewiesen.="" daraufhin="" wurde="" ambulant="" weiter="" substituiert="" mit="" kalzium="" und="" vitamin="" d="" 3="" .="" außerdem="" wird="" unter="" tsh-kontrolle="" l-thyroxin="" bis="" zur="" normalisierung="" substituiert.="" danach="" orale="" kalziumsubstitution.="" in="" diesem="" fall="" wurden="" –="" nach="" i.="" v.="" substitution="" bis="" zum="" unteren="" grenzwert="" in="" den="" klinik="" –="" kalziumkarbonat-tabletten="" (2.500="" mg="" kalziumkarbonat="" entsprechend="" 1.000="" mg="" kalzium="" in="" form="" von="" kalzium="" gamma®="" 1000-brausetabletten)="" verordnet.="" eine="" langzeittherapie="" (falls="" sich="" die="" nebenschilddrüsenfunktion="" auch="" in="" einem="" jahr="" nach="" op="" nicht="" erholt="" hat)="" ist="" ebenfalls="" möglich:="" 10.000–40.000="" ie="" vitamin="" d="" täglich="" oder="" dihydrotachysterol="" (dht)="" 0,25="" mg="" (tropfenform!)="" bis="" 1,5="" mg="" (kapseln),="" ebenfalls="" mit="" 1.000–2.000="" mg="" kalzium.="" die="" wirkung="" dieser="" langzeitpräparate="" setzt="" erst="" mit="" tage-="" bis="" wochenlanger="" verzögerung="" ein.="" ihre="" wirkung="" kann="" zudem="" nach="" dem="" absetzen/herunterdosieren="" noch="" wochenlang="" anhalten.="" hohe="" vitamin-d-dosen="" können="" zu="" überdosierung="" und="" schwer="" behandelbaren="" vergiftungen="" führen.="" daher="" sind="" aktive="" vitamin-d-metaboliten="" zur="" einstellung="" des="" gewünschten="" niedrig="" normalen="" serumkalziumspiegels="" zu="">

In order to avoid dangerous hypercalcaemia, close-knit and long-term at least quarterly checks of the calcium level are recommended in the setting phase.

Course The hypocalcaemia normalizes over the course of weeks. The thyroid metabolism is well adjusted. Ms. T. is symptom-free with regard to her (no longer present) thyroid gland - it is checked annually.

Summary In multinodular goiter, it is particularly difficult to assess the severity of the disease; a combination of ultrasound and scintigraphy is required, possibly also a fine needle biopsy. The therapy of choice for autonomic adenoma is radioiodine therapy or resection. Postoperatively, the occurrence of hypocalcaemia must be expected.


Palliative care “Colleague, I canceled the shoulder operation. It looks like a metastasis. "

History The 60-year-old Mr. R. is referred for surgery because of unbearable pain in his left shoulder with a rotator cuff rupture. Patient data Known diagnoses: ▪ Partial rotator cuff rupture left. Shoulder ▪ Coronary vascular disease ▪ Hypertension ▪ Euthyroid goiter diffusa Previous medication: ▪ L-thyroxine: 125 µg (1/0/0) ▪ Simvastatin: 40 mg (0/0/1) ▪ Ramipril: 5 mg (1/0/0 ) ▪ Metoprolol succinate: 47.5 mg (1/0/0) ▪ Tamsulosin: 40 mg (1/0/0) Anamnestics In the middle of the consultation, the orthopedic surgeon calls: “Mister colleague, I canceled the shoulder operation. It looks like a metastasis. ”The histology is suspicious of a hypernephroma metastasis - sonography reveals a mass in the right kidney (). In addition to multiple bone metastases, staging also shows settlements in both lungs. The re. Kidney is removed. Chemotherapy is unfortunately unsuccessful, so it is discontinued. The "exhausted", at this point already very emaciated and extremely weak patient is transferred home for care.

Fig.5.1 Sonographic findings on the right. Kidney: spherical mass, approx. 5 cm, slightly more echogenic than the renal parenchyma, growing into the renal pelvis. []

1. What do you talk about with the patient regarding the therapy goal? 2. You agree on a palliative therapy goal with the patient. What action are you taking? 3. Mr R. complains increasingly of pain in his shoulder and thorax. What are you doing? 4. Mr R. complains increasingly of shortness of breath. What are you doing? 5. Mr. R. becomes increasingly cloudy and hardly takes any more liquid or food. What do you do? Two days later he is passed out and very restless. The relatives are desperate because of his rattling breathing. Which measures are possible? 6. What tasks do you have to take on as part of the investigation and what measures do you have to take?

1.Therapy goal From the beginning, there was no curative therapy goal, as there was already extensive metastasis. From the oncological side, the therapy goal of extending life was defined after the operation. Now it is time to redefine the therapy goal together with the patient. Presumably, it makes sense to establish a consensus that the focus should no longer be on the lifespan, but rather on the quality of life: "Do not give life more days, but give days more life."

2. Palliative medicine measures Here, of course, it is primarily about the patient. However, the doctor must never lose sight of the relatives. Conversations with the patient

and relatives about the upcoming last common path require a high degree of empathy on the part of the doctor and all other helpers. Avoid overloading the relatives. If possible, several family members and other helpers should be included in the palliative network so as not to overload individual people. Depending on the individual situation, professional and voluntary helpers are available: ▪ Relatives ▪ General practitioner ▪ Specialists in clinic and practice ▪ SAPV teams (specialized outpatient palliative care) ▪ Nursing staff on an outpatient basis and in the clinic ▪ Social workers ▪ Physiotherapists ▪ Occupational therapists, psychotherapists ▪ Music, Art therapists, body therapists and respiratory therapists ▪ Pharmacists ▪ Diet assistants ▪ Hospice helpers (voluntary) ▪ Pastors ▪ Self-help groups ▪ Friends, neighbors and acquaintances You ask whether you have a living will as well as a power of attorney or care will, and offer to give the patient a handover to support and to certify that at the time these documents were drawn up there was no evidence of impairment of the capacity to make judgments. In addition, it should be agreed which life-sustaining measures (resuscitation, intensive medical therapy, inpatient admission, e.g. only for medical problems that can be safely resolved quickly, only mitigating measures in the home environment) are desired by the patient. Plan treatment in advance: ACP (Advanced Care Planning). The written documentation can e.g. B. be done using the PALMA arch (). In addition, an emergency plan must be drawn up which, in addition to information on life-sustaining measures, also contains the contact details of the caregivers (especially the authorized representatives / supervisors), the supervising doctors, the nursing service, if necessary the SAPV team, the hospice service and pastoral care, etc. In addition, the prescribed measures for symptom control should include both long-term medication and emergency medication, for example in the event of sudden pain, anxiety / restlessness, shortness of breath, nausea, delusions / delirium, etc. Information must be clearly visible. Above all, this must be clearly understandable for those doctors (emergency service, emergency doctor, hospital doctor) who do not know the patient and his current situation and wishes.


PALMA: patient instructions for life support measures


The medication should be checked critically and regularly adjusted to the current condition of the patient. Depending on the current therapeutic goal, "life-prolonging" drugs may have to be discontinued.

3. Pain therapy Pain therapy is based on the WHO level scheme (,).


WHO level scheme of pain therapy []

The following basic rules must be observed: ▪ Regular administration (p. O., C. C. Or by port) before the pain occurs ▪ Prophylaxis of opiate constipation ▪ Suitable co-analgesics such as dexamethasone, amitriptyline, anti-epileptic drugs, sedatives, bisphosphonates ▪ Prescribe antiemetics, if necessary