Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s main reason for presentation, typically involving:
Sudden onset of severe unilateral (one-sided) pelvic pain
Nausea and vomiting
May also report lower abdominal pain or pain radiating to the groin or thigh
History of Present Illness:
Onset, location, and character of pain (sudden, sharp, worsening)
Severity of pain (graded on a scale)
Associated symptoms (nausea, vomiting)
Past medical history (pelvic inflammatory disease (PID), ovarian cysts, endometriosis)
Past surgical history (pelvic surgeries)
Menstrual history (last menstrual period, regularity)
Pregnancy history (number of pregnancies, deliveries, and any complications)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be elevated with tachycardia (fast heart rate) if pain is severe.
General examination: Assess for signs of discomfort and potential dehydration from nausea and vomiting.
Abdominal examination:
Lower abdominal tenderness (may be localized to one side)
Pelvic tenderness on palpation (especially on the side of the affected ovary)
Cervical motion tenderness (pain with movement of the cervix) – suggestive of peritoneal irritation
Pelvic exam (may be deferred if pain is severe):
Uterine tenderness and possible adnexal mass (palpable on bimanual exam)
Imaging Studies (urgent evaluation is crucial):
Pelvic ultrasound: Doppler ultrasound is preferred to assess blood flow to the ovary and fallopian tube. The absence of flow suggests torsion.
CT scan (with contrast) – if ultrasound inconclusive or contraindicated: May be used to visualize the adnexa and rule out other causes of pelvic pain.
Assessment:
Diagnose adnexal torsion based on clinical presentation (sudden severe pain, unilateral tenderness) and imaging findings (absence of blood flow on Doppler ultrasound).
Consider the time elapsed since symptom onset – earlier surgical intervention is crucial for preserving ovarian tissue.
Plan:
Surgery is the definitive treatment for adnexal torsion.
Laparoscopy is the preferred surgical approach due to its minimally invasive nature.
The goal is to detorse (untwist) the ovary and fallopian tube to restore blood flow.
Oophorectomy (removal of the ovary) or salpingectomy (removal of the fallopian tube) may be necessary if tissue is necrotic (dead) due to prolonged torsion.
Pain Management: Administer intravenous pain medication for immediate pain relief.
Consultations:
Gynecological surgeon (for laparoscopic surgery)
Progress Notes:
Document the timing of surgery and surgical findings (detorted ovary, oophorectomy, etc.).
Monitor post-operative pain control and vital signs.
Note any complications (bleeding, infection).
Discuss discharge instructions and follow-up care.
Prognosis:
Prompt diagnosis and surgery are crucial for ovarian salvage. Delay can lead to tissue death and necessitate oophorectomy.
Prognosis depends on the time elapsed before surgery and the extent of tissue damage.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early recognition and surgical intervention are essential to minimize tissue damage and improve outcomes in adnexal torsion.