A-E Examination: Ovarian Torsion

Background and Presenting Complaint

• Miss Lee has a 2-hour history of severe sudden-onset lower abdominal pain. The pain is sharp and constant. The pain does not radiate anywhere and is 10/10 in severity. There are no triggering, relieving, or exacerbating factors. Her mum gave her paracetamol shortly after the pain started, but this did not help.
• She feels nauseous and has vomited once since the onset of pain. No blood in the vomit.
• No changes to bowel habits or urinary symptoms.
• No fever.
• Her last menstrual period was 5 days ago.
• She usually has regular periods. Her cycle length is 28 days. Her periods last 4 days on average. She denies ever having any problems with her periods, including heavy menstrual bleeding, intermenstrual bleeding, or dysmenorrhoea. Menarche occurred at age 12.
• She denies having abnormal vaginal discharge or vulvovaginal itching.
• She is not sexually active.

Past Medical History

• Nil Comorbidities

Drug History and Allergies

• Not taking any regular medications.
• She is allergic to penicillin and experiences anaphylaxis if she takes it

Introduce yourself, confirm the patient’s identify, and gain consent to examine the patient

• Patient confirms full name and DOB
• She gives consent for you to examine her

End of bed inspection

• She appears severely distressed and is writhing in pain

Airways

• Assess the patency of the patient’s airway, ensure that the patient is able to breathe effectively, and there are no airway obstructions.
  • Her airway is patent, as she is able to talk in full sentences 
  • There are no airway obstructions

Breathing

• Inspect for signs of respiratory compromise (e.g. cyanosis, see-saw breathing, use of accessory muscles, nasal flaring, pursed lip breathing, or increased work of breathing)
  • There are no signs of respiratory compromise
• Respiratory rate
  • RR = 20
• O2 sats
  • O2 sats = 99% on RA
• Palpate for tracheal deviation and symmetrical chest expansion
  • Trachea is central and there is symmetrical chest expansion
• Percuss
  • Percussion note is resonant throughout
• Auscultate for reduced breath sounds or added sounds
  • Vesicular breathing bilaterally
  • No added sounds

Circulation

• Inspection (e.g. pale, sweating, clammy)
• Temperature of hands
  • Warm and well-perfused
• CRT
  • 1 second
• Heart Rate
  • 110bpm
• Blood pressure
  • 110/70mmHg
• Insert 2 large bore IV cannulae into each antecubital fossae
  • Take bloods (FBC to look for anaemia and raised white cell count, U&Es and LFTs for baseline, CRP for infection/inflammation, and serum β-hCG to check for pregnancy)
• JVP
  • Not raised
• Apex beat
  • Palpable in the left 5th ICS midclavicular line
• Heart sounds
  • Normal
• Fluid status
  • Euvolaemic
• Perform an ECG
  • Sinus Tachycardia

Disability

• Level of consciousness (AVPU or GCS if a neurological cause for the patient’s presentation is suspected)
  • Alert
    
• Pupils
  • Equal and reactive to light
• Blood glucose levels
  • 5.0
• Temperature
  • 37.0°C

Exposure

• Fully expose the patient by removing their clothing whilst preserving their dignity
• Look for any signs of trauma, swelling, bruises, scars, rashes, or signs of a DVT
• Abdominal examination:
  • Severe tenderness in the lower abdomen. No abdominal rebound tenderness, rigidity, or guarding.

After completing the initial A-E assessment, reassess! Re-assess the patient to identify any additional clinical changes and effectiveness of any interventions you have performed.

1. What are your differential diagnoses?

• Ovarian Torsion (due to sharp, severe, sudden-onset lower abdominal pain that is associated with vomiting)
• Ruptured Ovarian Cyst (important differential in a female presenting with sharp, severe, sudden-onset lower abdominal pain)
• Appendicitis (important differential in someone presenting with lower abdominal pain)
• Ectopic Pregnancy (this is unlikely given the patient’s age and they are sexually inactive. However, it’s always important to consider ectopic pregnancy in a woman of childbearing age who presents with lower abdominal pain)

2. Given a likely diagnosis of Ovarian Torsion, how would you manage this patient?

• Call for help immediately
• Escalate to the obstetrics and gynaecology registrar and consult paediatrics
• Do a pregnancy test
• Order bloods (FBC, U&Es, LFTs, CRP, and serum β-hCG)
• Arrange for an urgent pelvic ultrasound (NB - A transvaginal ultrasound is more commonly performed; however, given her age, a pelvic ultrasound would be more appropriate)
• Prescribe analgesia
• Make the patient NBM and prescribe IV fluids based on the patient’s weight

3. Please Handover this patient to the obstetrics and gynaecology registrar using the SBAR or equivalent format.

• Hi, my name is Dr. Joe Bloggs and I’m calling from paediatric A&E. Can I please confirm who I am speaking to?
• I’m really worried about a patient I’ve just examined, I think she has ovarian torsion.
• She is a 14-year-old girl called Jess Lee who presented with a 2-hour history of severe, sharp, sudden-onset lower abdominal pain. She has vomited once since the onset of pain. 
• Her last menstrual period was 5 days ago and she is not sexually active. 
• She has no comorbidities or allergies.
• On inspection, she appeared severely distressed and was writhing in pain. 
• Her airway was patent
• Her respiratory rate was 20 and O2 sats were 99% on room air.
• She was haemodynamically stable. I have inserted 1 large bore IV cannula and have taken bloods, including FBC, U&Es, LFTs, CRP, and serum β-hCG. 
• She was alert, apyrexial, and her BM was normal.
• On examination, there was severe tenderness in lower abdomen. There was no rigidity or guarding. 
• I have done a pregnancy test, ordered a pelvic ultrasound, and prepped the patient for surgery (I’ve made her nil by mouth and have prescribed IV fluids). I’ve also prescribed paracetamol and an anti-emetic for her. 
• Can you please come and see her? In the meantime, is there anything you would like me to do?