Ovarian Torsion- Please, note that in both posts they are talking about a patient who was previously treated for Pelvic Inflammatory Disease and she came back with pelvic pain and the practitioners missed her diagnosis of Ovarian Torsion. Focus your answer on Ovarian Torsion and the impact on the patient’s health. What happened was that while the patient was being seen by the Dr, the physician was so busy and had to take care of more things and got a call to go take care of a patient in the Trauma unit and the nurse was interrupting the doctor frequently. Elaborate your answers based in the posts, this is just for you to have an idea of what’s going on. Thanks
Post 1
FaLa
After doing the cases, discuss the care of this 16 year old female including, but not limited to the following: physical examination, clinical management, education, possible long term sequelae, confidentiality
Diagnosing pelvic pain in an adolescent female can come with many challenges because of the broad range of conditions that attribute pelvic pain symptoms. Many of these conditions include ovarian cysts or torsion, endometriosis, dysmenorrhea, and many more conditions related to the reproductive system and health. Pelvic pain can also be related to other organ systems in the body such as gastrointestinal and renal. In short, pelvic pain can come from multiple sources in the body. Kayla’s physical exam was unremarkable, abdomen was soft and non-distended and she had mild tenderness in the left lower quadrant. Based on the symptoms and how quickly they progressed as well as location, the primary concern should be ovarian torsion. It is a rare diagnosis with an estimated incidence of 4.9 per 100,000 in women less than 20 years of age (Samuels-Kalow, M., & Mollen, 2015). The issue arising is that ovarian torsion is an ambiguous diagnosis as the physical factors can be misleading. However, the description of pain and symptoms experienced by the patient suggested presented the means to diagnose ovarian torsion. Ovarian torsion is an uncommon diagnosis and requires immediate attention. The narrowing of the ovary on its vascular causes obstruction, decreases blood flow to the area of the ovary, resulting in edema. Subsequently, arterial blood flow is reduced with resultant necrosis and inflammation of the peritoneum, which can result in permanent loss of the ovary if not corrected (Samuels-Kalow, M., & Mollen, 2015).
While laboratory studies can help in the diagnosis of other conditions causing abdominal pain, a pelvic ultrasound is the primary diagnostic when there is great concern for ovarian torsion. I would treat the pain and nausea with IV medications for comfort prior to the surgery. Early decision making to ovarian torsion increases the chance to preserve function. I would immediately refer her to a surgeon for further evaluation, hopping the surgeon could possibly try to save the ovary, because Kayla’s ability to have children could significantly decrease after Oophorectomy or Salpingectomy (Goolsby & Grubbs, 2015).
Follow-up care is highly recommended. She should avoid heavy lifting or vigorous physical activity for a few weeks. I would recommend for her to take over-the-counter medications, such as ibuprofen or acetaminophen to relieve pain and discomfort. In addition, she would be instructed to call the office for signs of infection or other complications as soon as possible include: fever, redness and inflammation at the incision sites, foul-smelling discharge, and increasing pelvic pain. There is a possibility of reappearance after detorsion also she should be told not to ignore a sudden, intense pain in in the pelvic area. Oral contraceptives method can be used to decrease the risk of recurrence (Schuiling, K, 2017).
Diagnosing adolescents can be an arduous challenge. Many factors should be considered such as confidentiality and the legal rights of adolescent as a patient. Establishing a trusting relationship will aid in helping the adolescent feel comfortable in order to provide an honest and complete history (Schuiling, K, 2017).
Post 2
TaLa
Diagnostic Excellence 3: 16 yr old female with pelvic pain.
After doing the cases, discuss the care of this 16 yr old female including, but not limited to the following:
Physical Examination
In this case study, a 16-year-old returned to the ER post previous diagnosis of Pelvic Inflammatory Disorder a few days earlier. She was previously prescribed doxycycline. Patient presented again due to extreme pain of 10/10, vomiting and L pelvic pain. The Emergency Department Physician elected to admit the patient for IV doxycycline stating that the medication can cause GI upset, and that teenagers can be complicated to treat. It was not helpful that the patient reported missing a dose due to vomiting. This led the physician to believe that the continued symptoms may be due to ineffective treatment. The physician also elected to skip the abdominal exam due to patient pain level and guarding of pelvic area. Completing a full physical examination was important to properly diagnose this patient. According to (Kruszka & Kruszka, 2010), differential diagnosis for acute pelvic pain include ectopic pregnancy, ruptured ovarian cyst, ovarian torsion, appendicitis, STI, and pelvic inflammatory disease (PID).
Clinical Management
Clinical management should include ruling out each differential diagnosis. Appendicitis and pregnancy were the only differential diagnosis that the case study advised were ruled out. The executed plan to admit for IV administration of doxycycline was not effective for this patient. Her ultimate diagnosis of Ovarian torsion was made 2 days later. A gynecologist had been consulted and diagnosed her with L ovarian torsion. The patient was subsequently taken to the operating room where her left ovary was noted to be necrotic and was removed. According to (Huang, Hong, & Ding, 2017), the most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.
Education
This week’s lesson outlines the normal thought processes when evaluating a patient and formulating differential diagnosis. These are noted as System 1 and System 2 Decision making. System 1 decision making “quick” decision making formulated over time by experience. According to (Aquifer, 2019), this can include relying on instincts, pattern recognition, and experience to guide decision-making occurring subconsciously and without much effort. In this case, the physician used this type of decision making given that he has seen this presentation may times with a diagnosis of PID. System 2 Decision making is more similar to what we as students use when seeing patients as we have less experience not having developed these instincts yet. System 2 decision making is slower and more analytical. According to (Aquifer, 2019), system 2 processes are deliberate and require mental effort and is often used by clinicians when a case is unfamiliar or complicated.
Possible Long-Term Sequelae
Upon diagnosis of ovarian torsion, laparoscopic surgery is the gold standard treatment with de-torsion noted as the goal of the surgical procedure. Per (Huang, Hong, & Ding, 2017), prompt intervention to preserve ovarian function should be laparoscopic wherever possible and de-torsion the treatment of choice in prepubescent girls and women of reproductive age whose families are not complete, regardless of the color of the ovary at the time of surgery. For this patient the ovary was not only black but necrotic causing it to be removed via unilateral oophorectomy. Long term effects include impaired fertility and hormone production. According to (Mayo Clinic, 2019), with the remaining ovary, women still have a menstrual cycle and the ability to conceive naturally.
Confidentiality
Information regarding her sexual activity, partners, and even if she were pregnant should be kept confidential. Depending on the requirement of the state, this patient ill likely need a parent to authorize the surgical procedure/treatment.
