Subjective
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Location and character of pelvic pain (aching, throbbing, dull)
Onset, duration, and frequency of pain
Worsening factors (activity, sexual intercourse, prolonged sitting)
Relieving factors (rest, supine position)
Associated symptoms (dyspareunia, vaginal heaviness, urinary frequency)
Menstrual cycle (changes in pain pattern)
Past medical history (relevant conditions like pelvic inflammatory disease, endometriosis)
Past surgical history (pelvic surgeries)
Obstetric history (number of pregnancies, deliveries, complications)
Medications (current medications, hormonal contraceptives)
Sexual history (activity level, partners)
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
Abdominal examination (tenderness, masses)
Pelvic exam (internal and external):
Uterine size and tenderness
Adnexal tenderness
Varicose veins in the vulva or vagina (if present)
Pelvic floor muscle tone (if indicated)
Assessment
Pelvic congestion syndrome (suspected) based on clinical presentation
Consider differential diagnoses (endometriosis, pelvic inflammatory disease, ovarian cysts, uterine fibroids)
Plan
Further evaluation (if needed):
Pelvic ultrasound (to rule out other causes)
Pelvic venography (specialized X-ray to visualize pelvic veins)
Treatment options will depend on severity and patient preference:
Conservative measures:
Lifestyle modifications (compression stockings, weight management, exercise)
Pain management medications (NSAIDs)
Hormonal therapy (progestin-only contraceptives)
Minimally invasive procedures (consider referral):
Embolization of pelvic varicose veins
Uterine artery embolization
Surgical intervention (consider referral in severe cases):
Laparoscopic ovarian vein ligation
Follow-up
Schedule for next appointment:
Discuss treatment plan and expected outcomes
Monitor response to treatment
Consider referral to a specialist (vascular surgeon, interventional radiologist) if needed
Note: This is a template and may need to be modified based on the individual patient’s presentation and severity of symptoms.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pelvic congestion syndrome.