Doctor Patient Relationship

Two simple models on doctor patient relationship.One is doctor as an expert adviser and  the other is doctor in partnership.

Doctor as an expert adviser  

• Docotor defines the patient's needs
• Doctor advises the patient what to do
• Doctor solves problems for the patient
• Doctor decide how much information to be given to the patient

Doctor  in  partnership

• Doctor elicit the patient's problems & needs
• Doctor explains the options to the patient
• Doctor and the patient explore the solutions to gether
• Doctor ask what information the patient wants

What is your style ?

 Emanuel and Emanuel ( JAMA. 1992 Apr 22-29;267(16):2221-6.) elaborated four models of doctor patient relationships:

1. Paternalistic: physician makes decisions for the patient’s benefit independent of the patients values or desires
2. Informative: physician provides information, patient applies values and decides.
3. Interpretive: patient is uncertain about values, physician, as counselor, assists the patient in elucidating his or her values.
4. Deliberative: Patient is open to development, physician teaches desirable values

Interestingly another article,Physician-Patient Relations: No More Models, argues that one model doesn't fit all.Based on my experience,I agree with this article.What do you think?

Induction of labour

Induction of labour

View more presentations from Ravimohan Ravimohan

Postpartum thyroiditis

Definition:
(i)It is an autoimmune disorder

(ii)It is chracterised by lymphocyte infiltrate of thyroid gland

(iii)There is transient hyperthyroidism followed by hypothyroidism or one or other

(iv)It occurs  in the first year of delivery.


The condition is more common on patients with family history of hypothyroidism, those with thyroid peroxidase antibodies and patients with type 1 DM.

3 phases of classical postpartum thyroiditis

(i)hyperthyroidism

(ii)hypothyroidism

(iii)recovery


1/3 of patients develop permanent hypothyroidism


Clinical features

presentation is usually between 3 to 4 months after delivery

(I)classical features of hyper or hypothyroidism is rarely observed
hyperthyroidism(palpitations,fatigue)
hypothyroidism(lethargy,depression)

(II)painless enlargement of the gland

(III)depression


Investigations

(I)thyroid function tests

(II)thyroid peroxidase antibodies.

(III) radioactive iodine uptake test may be necessary to differentiate from Graves' disease but this test can't be done in breast feeding mothers.

(*Thyroid receptor antibodies are present in Graves' disease)

Management

Most patients recover spontaneously.
Treatment should be determined by symptoms rather than biochemistry.

hyperthyroid phase needs treatment beta blockers but not with antithyroid drugs.

hypothyroidism needs with treatment thyroxine. Only 3-4 % of women remain permanently hypothyroid.




References

(i)Post-partum thyroiditis – a clinical updateElio Roti and Ettore degli Uberti.European Journal of Endocrinology (2002) 146 275–279
(ii)Nelson-Piercy C. Handbook of obstetric medicine. Taylor & Francis; 2002.

(iii)Swiet MD. Medical disorders in obstetric practice. Wiley-Blackwell; 2002.

Uterine rupture

2 types
(I) Uterine dehisence-separation of a preexisting scar without the disruption of parietal peritoneum.
(II)uterine rupture-full thickness disruption of uterine wall.

Risk factors

(I)previous caesarean section(Classical &Lower segment)
(II)Previous uterine surgery-myomectomy
(III)Grand multi parity
(IV)oxytocin
(V)prostaglandins

Clinical features

Uterine dehisence could be asymptomatic
(I)continuous lower abdominal pain
(II)fetal distress
(III)receding presenting part in labour
(IV)loss of uterine contractility during labour
(V) Haematuria/Bleeding per vaginum
(VI)Maternal tachycardia & hypo tension are late signs

Stair case sign-stepwise gradual decrease in contraction amplitude has been reported in uterine rupture.


Treatment

This is an Obstetrics emergency

resuscitation & surgery should go hand in hand.
call for Senior help(Obstetrician & Anaesthetist)
IV access
Arrange Cross matching of Blood(6-10 units)
Allocate one person to scribe the events
Keep the family informed during the procedure
Debrief at the end of procedure


If uterine rupture occurs prior to delivery emergency caesarean section should be done.
The following options can be selected according type of tear,state of the patient and  ongoing blood loss.
(I)uterine repair
(II)Hysterectomy
(III)Internal artery ligation



Powerpoint on uterine rupture
References
(I)E Medicine
(II)Successful management of gravid uterine rupture.Taiwan J Obstet Gynecol. 2009 Sep;48(3):319-20.Authors: Fu PT Chen CH Wu GJ Yu MH.PMID: 19797032 [PubMed - indexed for MEDLINE]
(III)Spontaneous uterine rupture-Case report and  review

Mnemonic for Chronic pelvic pain

I found this very useful mnemonic in a book called Practical Gynecology -A Guide for the primary physician(Amazon Link)



OLD CAARTS

O-Onset When & How the pain started?
L-Location
D-Duration

C-Characteristic -colicky/stabbing/burning
A-Alleviating/Aggravating factors
A-Associated symptoms Gynacologic-Dyspareunia,dysmenorrhagia,vaginal discharge GI-constipation/diarrhoea/Rectal bleeding GU-frequency/dysuria/urgency/incontinence

R-radaition
T-Temporal what is the relationship to (i)time the day (ii)menstrual cycle
S-severity Sclae of 0-10


International criteria for painful bladder syndrome


(i) Urinary urgency,frequency,nocturia,and suprapubic or pelvic pain.
(ii)Final diagnosis for interstitial cystitis : with cystoscopic hydrodistension visualise
(i)Mucosal ulcers(Hunner's patch)
(ii)Glomerulations(small mucosal haemorrhages)
(iii) Urine cultures negative and no signs of malignancy


Rome III Criteria for Diagnosis of irritable Bowel syndrome

Recurrent abdominal pain for or discomfort for more than or equal to 3 days /month for the past 3 months associated with two or more  of the following.

(i)Improvement with defecation and/or

(ii)Onset associated with a change in frequency of stool and /or

(iii) Onset associated with a change in form (appearnce) of stool

PDF source

Obgyn Twitter News paper

Management of tubal ectopic pregnancy

Check out this SlideShare Presentation:

Management of tubal ectopic pregnancy

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Peripartum cardiomyopathy

Definition:


(1)development of heart failure in the last month of pregnancy within 5 months after delivery
(2)absence of a known cause
(3) without any heart disease prior to the last month of pregnancy
(4) documented systolic dysfunction


Risk factors
Advanced maternal age
Multiparity
PIH
Multiple pregnancy
Afro-Caribbean race


Symptoms

fatigue
Dyspnoea/paroxysmal nocturnal dysponea
palpitations
pulmonary oedema/peripheral oedema
features of peripheral/cerebral embolism



Signs

elevated JVP
Cardiomegaly
third heart sound

Mitral/Tricuspid regurgitation

crepitations
hepatomegaly
Ascites




Systemic embolism occurs in 25-40% of patients with cardiomyopathy.
Investigation-Diagnostic criteria

Left ventricular ejection fraction <45%>

Left ventricular end diastolic pressure (LVEDP) >2.7cm/m2


Fractional shortening <30%>Chest Xray-Cardiomegaly/Pleural effusion/patchy lower lung infiltrates vascular redistribution

ECG- may helpful in excluding other causes

Endomyocardial biopsy done some times.

Invasive haemodynamic monitoring is considered if there is not a good response to medical treatment.

Newyork heart association classification can be used
I- asymptomatic
II-mild symptoms or symptoms only with extreme exertion
III-Symptoms on minimal exertion
IV- symptoms at rest Management


conventional treatment for heart failure is generally used.

Diuretics
vasodilators(hydralazine &/ nitrates)
cardio selective beta blockers(bisoprolol) or beta blockers with vasodilating action (carvedilol)

digoxin
ionotropes
ACEI-after delivery

salt restriction is recommended

Thromboprophylaxis

Elective delivery if antenatal.If cervix is favourable vaginal delivery is preferable,otherwise caesarean section may be chosen.Skilled epidural anaesthesia is useful for both routes of delivery.

Immunosuppressive therapy if myocarditis confirmed by endometrial biopsy.

Temporary support can be given by intraaortic balloon pumps & left ventricular assist devices.

Cardiac transplantation is indicated if intractable heart failure persists optimal medical therapy


Postpartum
Breast feeding isn't contraindicated.


Prognosis

Outcome of peripartum cardiomyopathy is variable.
Some patients recover rapidly but others may deteriorate to state requiring cardiac transplantation.
50% of patients make full recovery.
Echocardiography is repeated every six months to assess the recovery.
Prognosis depend on recovery of left ventricular size & function within 6 months.

Persistence of cardiac dysfunction beyond 6 months an indication of irreversible damage and such should be advised against pregnancy

Stress echocardiogram using dobutamine can be used to assess the contractile reserve.This would help in pre pregnancy counseling.Recurrence rate has been upto 50%

4.In future pregnancy women should have regular echocardiography


Sources

1.	Nelson-Piercy C. Handbook of obstetric medicine. Taylor & Francis; 2002.

2	Swiet MD. Medical disorders in obstetric practice. Wiley-Blackwell; 2002.

3.E-medicine

4.	Peripartum Cardiomyopathy [Internet]. 2001 May 24 [cited 2009 Dec 12];Available from: http://content.nejm.org/cgi/content/extract/344/21/1629

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