Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Evaluation for suspected ovarian hyperstimulation syndrome (OHSS)
Follow-up for diagnosed OHSS (monitoring symptoms, managing
complications)
Evaluation of abdominal pain, bloating, or other symptoms
Chief Complaint:
Abdominal pain or bloating (often the most prominent symptom)
Nausea and vomiting
Difficulty breathing (severe cases)
Pelvic pain or pressure
Feeling full or tight in the abdomen
Rapid weight gain (due to fluid accumulation)
Decreased urination
History of Present Illness:
Onset, duration, and severity of symptoms.
Recent assisted reproductive technology (ART) cycle (e.g., in vitro
fertilization [IVF]) – a major risk factor.
Medications used during the ART cycle (type and dosage of fertility
drugs).
Previous episodes of OHSS (increases risk of recurrence).
Past Medical History:
Underlying medical conditions (e.g., polycystic ovary syndrome [PCOS])
that may increase risk of OHSS.
Previous surgeries (relevant surgeries on the ovaries or pelvis).
Family History:
Not typically relevant for OHSS.
Social History:
Not typically relevant for OHSS.
Physical Examination:
General examination: Assess vital signs (may be elevated in severe
cases).
Abdominal examination: Evaluate for distention, tenderness, ascites
(fluid collection in the abdomen), and enlarged ovaries.
Pelvic examination: Palpate for ovarian enlargement and tenderness.
May be deferred in severe cases due to discomfort.
Diagnostic Tests (if indicated):
Pelvic ultrasound: Visualize the ovaries for size and presence of
multiple follicles (fluid-filled sacs) – a hallmark of OHSS.
Blood tests: May include electrolyte levels, hematocrit (red blood cell
count), and liver function tests to assess for potential complications
(e.g., electrolyte imbalances, dehydration).
Assessment:
Ovarian hyperstimulation syndrome (OHSS): Based on clinical
presentation (symptoms and physical examination findings) and supported by
ultrasound findings.
Severity of OHSS: Classification systems categorize OHSS based on
severity (mild, moderate, severe, critical). Severity is determined
by symptoms, physical examination findings, and ultrasound features.
Differential Diagnoses:
Consider other conditions that may mimic OHSS:
Pelvic inflammatory disease (PID)
Ovarian torsion (twisting of the ovary)
Ectopic pregnancy
Plan:
Treatment plan: Depends on the severity of OHSS.
Mild cases: May be managed with conservative measures at home,
including bed rest, pain management, oral fluids, and monitoring
urinary output.
Moderate to severe cases: Hospitalization may be necessary for
intravenous fluids, electrolyte management, close monitoring, and
supportive care.
Severe/critical cases: Drainage of excess fluid from the abdomen
(paracentesis) may be needed in rare cases.
Pain management: Medications to manage abdominal pain and
discomfort.
Dietary modifications: Low-sodium diet to minimize fluid
accumulation.
Supportive care: Monitor vital signs, urine output, and electrolyte
balance.
Prevention of dehydration: Encourage adequate oral intake (if tolerated) or intravenous fluids as needed.
Follow-up: Schedule close follow-up appointments to monitor
symptoms and resolution of OHSS.
Prognosis:
Most cases of OHSS resolve spontaneously within a few weeks. The
prognosis depends on the severity and prompt initiation of treatment.
Patient Education:
Educate the patient about OHSS, causes, symptoms, risks, and
management strategies.
Discuss the importance of following treatment recommendations and
monitoring symptoms.