Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for a suspected ovarian cyst
Follow-up for a known ovarian cyst (monitoring size, symptoms)
Evaluation of pelvic pain or other symptoms
Chief Complaint:
May be asymptomatic (especially small cysts)
Pelvic pain or pressure (can vary depending on cyst size and location)
Pelvic fullness or bloating
Abnormal vaginal bleeding or spotting (less common)
Difficulty urinating or urinary frequency (if cyst presses on bladder)
Pain during intercourse (if cyst presses on other pelvic structures)
History of Present Illness:
Onset, duration, and severity of symptoms.
Presence of any risk factors for ovarian cysts (e.g., endometriosis,
polycystic ovary syndrome [PCOS], previous pregnancy).
Previous history of pelvic surgeries or treatments.
Past Medical History:
Underlying medical conditions.
Previous diagnoses of ovarian cysts or other pelvic conditions.
Family History:
Family history of ovarian cysts or other gynecological conditions.
Social History:
Tobacco use (may increase risk of certain types of ovarian cysts).
Physical Examination:
Pelvic examination: Palpate for ovarian masses, tenderness, or
adnexal
(uterine appendages) enlargement.
Abdominal examination: Assess for distention or tenderness.
Diagnostic Tests (if indicated):
Pelvic ultrasound: Initial imaging test to visualize the ovaries and
characterize the cyst (simple, complex). Simple cysts are usually round
and
filled with fluid, while complex cysts may have solid components or
internal debris.
CA-125 blood test: Tumor marker that can be elevated in some ovarian
cancers but is not specific for ovarian cysts and can be normal.
CT scan or MRI scan: May be used in certain situations to further
evaluate complex cysts or rule out other diagnoses.
Assessment:
Ovarian cyst: Based on pelvic ultrasound findings. The description
should include size, laterality (one or both ovaries), and characteristics
(simple or complex).
Symptoms: Correlate symptoms with the cyst’s characteristics
(e.g.,
larger cysts more likely to cause pressure symptoms).
Risk of malignancy: Consider the patient’s age, symptoms, and
ultrasound findings. Simple cysts in younger women are less suspicious for
cancer compared to complex cysts or cysts in postmenopausal women.
Differential Diagnoses:
Consider other conditions that may mimic ovarian cysts:
Pelvic inflammatory disease (PID)
Ectopic pregnancy
Uterine fibroids
Plan:
Management plan: Depends on the size, complexity, symptoms, and
patient’s age. Options may include:
Watchful waiting: Monitoring the cyst with serial ultrasounds
is often recommended for asymptomatic simple cysts, especially in
younger women.
Hormonal birth control: May help prevent new cyst formation
and
regulate menstrual cycles.
Surgery (laparoscopy or laparotomy): May be recommended for
symptomatic cysts, complex cysts, or cysts that persist or grow during
watchful waiting. Surgery may also be necessary if malignancy is
suspected.
Pain management: Over-the-counter medications or prescription
pain medications may be needed to manage pelvic pain associated with
the cyst.
Follow-up: Schedule follow-up appointments with pelvic ultrasounds
to monitor the cyst’s stability or resolution. Frequency of follow-up
will depend on the initial characteristics and management plan.
Prognosis:
Most ovarian cysts are benign (non-cancerous). Simple cysts often
resolve on their own. The prognosis depends on the type and management
approach.
Patient Education:
Educate the patient about ovarian cysts,
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types, symptoms, diagnosis,
and treatment options.