Ovarian Cyst Case Study

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Pertinent Positives and Pertinent Negatives.

Pertinent positives include right lower quadrant abdominal pain, mid menstrual cycle. The patient is premenopausal, which is another pertinent positive. Pertinent negatives include a negative family history of ovarian cancer, BRCA gene, Lynch syndrome. The absence of nausea and vomiting, abnormal bleeding, negative pregnancy test. The cysts are

Plan

MH is a 34 year old female with a past medical history of anxiety and a left breast cyst/dense breast tissue, who presents for right lower quadrant abdominal pain midway through her menstrual cycle. Blood work, urine testing and imaging were obtained. Based on these results, she has been diagnosed with follicular cysts of the right ovary. She may continue using supportive treatments such as the application of heat and ibuprofen for discomfort. The patient may initiate use of oral contraceptive pills to prevent the formation of additional functional ovarian cysts.

Follow Up Visit.

On a follow up visit, the patient states she has experienced similar, right sided pain related to some of her more recent cycles, that has resolved on the completion of her menses. She has treated the pain with ibuprofen and the application of heat and she feels comforted knowing what is responsible for the discomfort. She has not yet determined if she would like start oral contraceptive pills as she is unsure of her and her partner’s plans regarding having children.

Analysis of Case

The adnexa consists of the fallopian tubes, ovaries and the ligaments. Adnexal masses are a gynecologic condition for which patients seek care. Ovarian masses are a common gynecologic condition, and it is estimated that the prevalence varies widely between 8% and 18% in pre and post-menopausal women (Ross & Fortin, 2016). 70% of non-inflammatory tumors are functional cysts, 20% are neoplastic and about 10% are endometriomas (Grabosch & Helm, 2016). Due to the concern for ovarian cancer and other abdominal emergencies, an appropriate and thorough work up is necessary for an accurate diagnosis.

In analyzing the aforementioned case, risk factors for ovarian cancer should be reviewed to better understand the patient’s risk factors, and more accurately and surely diagnose a low risk ovarian cyst. A thorough and complete family history should be obtained due to the fact that family history is the single greatest risk factor for ovarian cancer (Lockwood-Rayermann, Donovan, Rambo & Kuo, 2009). Previous use of oral contraceptives, long acting reversible contraceptives and any other contraceptives, as well as the use of unopposed estrogen, should be inquired about. The patient’s smoking and BMI history should be reviewed and inquired about if data is unavailable in the chart. Dyspareunia should be inquired about, as well as a history of mitttelschmerz. Presence of abdominal symptoms such as dyspepsia, early satiety and sensations of abdominal fullness should be assessed in the patient as well.

The patient’s urine pregnancy test was negative and urinalysis was negative for infection and protein. Her blood work resulted within defined limits. Acute bleeding would have been evident in the CBC. Torsion and other complications of ovarian cysts as well as an appendicitis would have also been made evident by leukocytosis, decreased hematocrit and other alterations in the complete blood count. Kidney stones and urinary tract infections would have been made evident by the urinalysis. Abnormal pelvic exam, including abnormal cervical discharge and cervical motion tenderness, none of which were evident in this exam, would have been concerning for PID. While the exam and diagnostic process seems thorough, additional bloodwork should be obtained, including beta-human chorionic gonadotropin to rule out ectopic pregnancy in premenopausal women. If family history, exam or imaging caused concern for ovarian cancer, cancer antigen 125, a protein expressed on the cell membrane of normal ovarian tissue and ovarian carcinomas, should be assessed as an elevated level is associated with ovarian cancer. It should be noted that the marker may be raised in some patients who do not have cancer, but are experiencing some other abdominal/ovarian process. The OLDCART method of pain assessment should be more thoroughly used in assessing the patients pain, with specific consideration to the aggravating and relieving factors, as well as history of the pain as this would help to rule out other differentials, which will be discussed next.

Differential Diagnoses

Life threatening causes of abdominal and or pelvic pain should be excluded before the diagnosis of low risk ovarian cyst is made. Some emergent conditions include ovarian torsion, tubo-ovarian abscess, appendicitis, ectopic pregnancy, and renal calculi. Some differential diagnoses for right lower quadrant, abdominal or pelvic pain include endometriosis, inflammatory bowel disease, bowel obstruction, pelvic inflammatory disease, appendicitis and ovarian cancer.

Appendicitis is the inflammation of the appendix, which projects from the colon in the right lower quadrant. Appendicitis causes pain that typically begins periumbilical, and then travels to the right lower quadrant. Pain is generally sudden in onset and progresses to severe. This pain is worsened by coughing, walking, jumping or raising legs. Nausea and vomiting, anorexia, fever, constipation, diarrhea, abdominal bloating and leukocytosis are signs and symptoms associated with appendicitis. Abdominal ultrasound would demonstrate inflammation of the appendix, and free fluid would suggest rupture of appendicitis (Mayo Clinic, 2014).

Ovarian cancer, often described as a “silent killer” is now associated with some signs and symptoms. Many women diagnosed with ovarian cancer describe abdominal symptoms like bloating, gas and abdominal distention, some report indigestion, constipation and nausea. Fewer women describe abdominal pain, pain with intercourse, back pain, urinary frequency and incontinence, fatigue, anorexia and weight loss. Even fewer women report bleeding and or a palpable mass as pelvic symptoms (Lockwood-Rayermann, et. al., 2009). The Foundation for Women’s Cancer describe the most common symptoms as bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly and or urinary symptoms including frequency or urgency. These symptoms were listed under the ovarian cancer symptoms consensus statement to increase awareness (Foundation for Women’s Cancer, 2016). As previously mentioned, family history of ovarian or breast cancer would most