Ovarian Cyst Case Study

Ovarian Cysts

This paper is a diagnostic clinical analysis on the management of a common gynecologic condition. It consists of the clinical case in subjective, objective, assessment and plan (SOAP note) format, an analysis of the case and a plan for management. An overview of the clinical condition also will be reviewed and the appropriate differentials, diagnostic tests and treatment plan will be discussed in detail.

Clinical Case

The clinical case was managed by the nurse practitioner student, with input and final approval from the women’s health preceptor. The case will be described in this section, including the history of present illness, physical assessment and exam, the past medical and surgical history, as well as the diagnostic testing results available for this patient. The patient will be referred to as MH. She is a 34 year old, Caucasian female. She works as a nurse. She presented to her Gynecologist earlier this year with the chief complaint of abdominal pain.

Subjective

History of Present Illness.

The patient reports onset of right sided abdominal pain July 14th, 2016, which she notes as the 19th day of her cycle. She describes the pain as a dull, consistent ache that became more pronounced after four days. She states that the pain is sore, but not unbearable. She localizes the pain to her right “pelvic” area. She states she applies heat to the area, and takes 600mg ibuprofen with some relief. She denies abnormal bleeding or spotting. She denies nausea and vomiting as well as changes in her normal bowel or bladder function. She denies a change in the consistency, quality, amount and or smell of discharge, she denies itching and vaginal or urethral discomfort.

 She denies changes in her diet. She denies chance of pregnancy. In terms of social history, she denies smoking and the use of illicit substances and reports very occasional ETOH use, mostly wine. She denies a family history of BRCA gene mutation, Lynch syndrome and ovarian cancer.

Gynecologic Health History.

The patient states onset of menarche was 12 years of age. She reports a menstrual cycle length of 29 days. She states bleeding lasts 4-5 days. She reports that her cycles are regular and uncomplicated, with the exception of light spotting sometimes two days before. She is G0P0. She is sexually active, in a long term, monogamous relationship. She using natural family planning as a method of contraception, she tested negative for sexually transmitted infections prior to this relationship and she is not concerned about possible infection at this time.

 Past Medical History.

The patient’s past medical history includes: anxiety, left breast cyst, dense breast tissue (per MRI). She has no past surgical history. The patient takes Xanax PRN for anxiety and ibuprofen as needed for discomfort associated with abdominal pain. She takes evening primrose oil for left breast discomfort. She takes supplements including magnesium with calcium, omega fatty acids 3-6-9 and flax seed oil. She denies allergies to food, environment or medications.

Objective

Physical Exam.

Her physical exam is as follows.

Vital Signs: BP 118/80 left arm, pulse 78, SpO2 100% on room air, temporal temperature 36.8C pain 3/10 in the right lower quadrant. Height 5’6, weight 135 lbs.

Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. She does not appear to be distressed.

HENT:

Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.

Nose: Nose normal.

Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.

Eyes: Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.

Neck: Normal range of motion. No thyromegaly or lymphadenopathy present.

Cardiovascular: Regular rhythm, regular rate. No additional heart sounds, murmurs, gallops or rubs appreciated.

Pulmonary/Chest: Effort normal. Breath sounds clear to auscultation. Respirations regular and unlabored.

Abdominal: Positive bowel sounds.  Non-distended, soft to palpation. Tenderness to palpation in right lower quadrant.  No rebound tenderness or rigidity.  Denies CVA and suprapubic tenderness.
Musculoskeletal: Normal range of motion. Gait non atalgic.
Lymphadenopathy:  She has no cervical, axillary, supraclavicular, inguinal or femoral adenopathy.
Neurological: She is alert and oriented to person, place, and time.
Psychiatric: Her behavior is normal. Judgment and thought content normal.

Pelvic examination: EGBUS normal, vulva is normal, vagina is without lesions or discharge, cervix is without lesions or discharge, uterus is normal, nontender and no masses present. Adnexa/parametria, normal, tender to palpation right side, no masses to palpation.

Diagnostic Testing.

A transvaginal and an abdominal ultrasound were ordered.

A urine pregnancy test was ordered and obtained, as was a urinalysis. The patient had not had bloodwork in several years (at any of her annual visits here or with her primary care provider) and therefore this practice felt as though it would be appropriate to order comprehensive blood work. A CBC and BMP were obtained.

Assessment

Differentials.

Based on the patient’s description of the pain, the most likely differential diagnosis is ovarian cysts (functional). Less likely but diagnoses that were considered were appendicitis, renal calculi, urinary tract infection, ovarian torsion, ectopic pregnancy. These differentials were ruled out based on physical examination, patient presentation, imaging and lab values.

Diagnostic Testing Results.

Urine pregnancy test: negative.

Urinalysis: showed no leukocytes, RBC or nitrites.

Sodium 141, potassium 4.0, creatinine 0.77, GFR 86, calcium 8.9, phosphorous 3.7, magnesium 1.6, glucose 80, WBC 8.8, RBC 4.3, hgb 12.3, hct 37, platelets 183.

Result of imaging: abdominal ultrasound revealed no free fluid, the appendix was visualized and was unremarkable. No wall thickening, gallstones, sludge or enlargement of the gallbladder was noted. Transvaginal ultrasound found the cervical length to be 7cm. The right ovary measured 3cm long by 1.6 cm wide, 0.6 cm thick, the left ovary measured similarly, within defined limits for normal ovarian size. The right ovary showed two simple cysts <2cm, unilocular, thin, smooth walls, no solid or well-vascularized components, with normal surrounding vessel. Ovarian stroma was visualized between the two cysts. hyperechoic areas were visualized in both cysts.