Ruptured Ovarian Cyst
You are the general surgery CT1 asked to see a 16-year old girl with sudden onset right iliac fossa pain. How would you proceed.
Example answer introduction
In this scenario I would be most worried about appendicitis although my differentials will include ruptured ovarian cyst, mesenteric adenitis, ureteric stone and urinary tract infection. I would assess this patient using an A-E approach, take a focused history and perform an abdominal examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions.
Focused history
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Allergies
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Medications
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Past medical history – inflammatory bowel disease, previous abdominal surgery, gynaecological history including LMP
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Last meal
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Events leading up to this point - nature of pain, nausea and vomiting, altered bowel habit, weight loss, PR/PV bleeding
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Sexual history
Abdominal examination
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Inspect – Distention, surgical/traumatic scars, hernia, Cullen’s sign
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Auscultate – bowel sounds
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Palpate – Tenderness, guarding, rebound tenderness, Rovsing’s sign
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Percussion – Normal or hyper-resonant
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Digital rectal and pelvic examination –Anal tags, fissures, blood, mucus
Initial management
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IV crystalloids and catheter to maintain urine output of 0.5ml/kg/hr
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Analgesia according to WHO ladder
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Keep nil by mouth
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Inform general surgery and gynaecology registrars
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Keep patient and any relatives informed
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Document, document, document!!!
Key Points:
This scenario highlights the need to keep a wide differential. You will often meet this scenario in your training where the gynaecology team will not accept the patient unless appendicitis has been ruled out, so you will be called to work up the patient. Ruptured ovarian cysts are generally managed conservative unless there is heavy or ongoing bleeding. The gynaecology team will take over care and decide on further management. Your role in this scenario is to ensure the patient is ready for theatre if required.