How to document patient with adnexal neoplasm What to add in history of present illness? No pdf
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Documenting a Patient with Adnexal Neoplasm - History of Present Illness (HPI)
The HPI for an adnexal neoplasm needs to capture symptom characterization, relevant gynecologic context, risk stratification data, and timeline of discovery. Here is what to include, section by section:
1. Chief Complaint & Mode of Discovery
- Was the mass found incidentally (during routine pelvic exam, obstetric ultrasound, or imaging done for another reason) or did the patient present with symptoms?
- The majority of adnexal masses are detected incidentally on obstetric/gynecologic ultrasound; some are diagnosed due to symptoms from size or complications. - Creasy & Resnik's Maternal-Fetal Medicine
2. Presenting Symptoms (Onset, Duration, Character, Severity)
Document the Ovarian Cancer Symptom Index - the four cardinal symptom clusters. These are meaningful when newly developed, persistent, or changed in character: - Schwartz's Principles of Surgery, 11th Ed.
| Symptom | Details to Capture |
|---|---|
| Bloating / abdominal distension | Onset, persistence, severity |
| Pelvic or abdominal pain | Location, quality, radiation, severity (0-10), constant vs. intermittent |
| Difficulty eating / early satiety | How quickly the patient feels full, appetite loss |
| Urinary symptoms | Urgency, frequency, incontinence (new onset) |
Additional symptoms to document per Berek & Novak's Gynecology:
- Back pain
- Fatigue
- Indigestion / nausea
- Constipation
- Unexplained weight loss or gain
- Inability to eat normally
Document whether symptoms are new in onset, persistent, or represent a change from baseline - these features increase clinical concern.
3. Pain Characterization (if present)
- Location: right/left/bilateral lower quadrant, midline, diffuse
- Onset: sudden (torsion?) vs. gradual
- Character: sharp, dull, crampy, pressure-like
- Radiation: to back, thigh, shoulder tip
- Relation to menstrual cycle: worse at specific cycle phases (suggests endometrioma, functional cyst)
- Associated nausea/vomiting (may indicate torsion or rupture)
4. Menstrual History
Per Textbook of Family Medicine, 9th Ed. - this is one of the key historical details:
- LMP (last menstrual period)
- Menopausal status - critical: postmenopausal women have higher malignant risk for any ovarian mass
- Cycle regularity, frequency, duration
- Menorrhagia or abnormal uterine bleeding
- Dysmenorrhea (suggests endometriosis/endometrioma)
- Dyspareunia
5. Risk Factors for Ovarian Malignancy
These are essential HPI/history elements that stratify risk - Schwartz's Principles of Surgery:
Hormonal/Reproductive risk factors:
- Age at menarche (early menarche = higher risk)
- Age at menopause (late menopause = higher risk)
- Parity (nulliparity increases risk)
- Oral contraceptive use (reduces risk - up to 30 years after stopping)
- Prior tubal ligation or hysterectomy (decreases risk)
- Infertility / IVF history
Genetic/Family history:
- First-degree relatives with ovarian or breast cancer (one of the strongest risk factors)
- Personal or family history of BRCA1/BRCA2 mutation
- Hereditary syndromes: Lynch syndrome (HNPCC), hereditary breast-ovarian cancer syndrome
- Personal history of breast, endometrial, or colon cancer
Note: up to 50% of women with ovarian cancer who test BRCA-positive have NO family history of either malignancy. BRCA status should still be asked. - Schwartz's Principles of Surgery, 11th Ed.
6. Associated Gynecologic History
- Prior pelvic infections / STIs (risk for tubo-ovarian abscess, ectopic)
- Prior pelvic/abdominal surgery
- Prior ovarian cysts - were they followed, and what happened to them?
- History of endometriosis
- Pregnancy status (positive hCG rules out malignancy in many functional masses; adnexal masses are found in 1-4% of pregnant women)
- Previous imaging findings and dates
7. Symptoms of Hyperandrogenism (if applicable)
Per Textbook of Family Medicine - document for cases where PCOS, androgen-secreting tumor, or Sertoli-Leydig cell tumor is on the differential:
- Hirsutism
- Acne
- Irregular menses / oligomenorrhea
- Voice changes, clitoromegaly (virilization - rare, suggests androgen-secreting tumor)
8. GI and Urinary Review Related to the Mass
- Change in bowel habits: constipation, diarrhea, tenesmus
- Urinary frequency, urgency, hesitancy, hematuria
- Symptoms of obstruction or pressure effect
9. Systemic / Constitutional Symptoms
These suggest malignancy and must be captured:
- Unintentional weight loss
- Fatigue and malaise
- Night sweats
- Decreased appetite / early satiety (already in symptom index but document quantitatively)
- Abdominal bloating and increased abdominal girth (ask if clothes fit tighter)
10. Timeline Summary
Document a clear chronological narrative:
- When were symptoms first noticed?
- When was the mass first detected (clinically or on imaging)?
- Has it changed in size or character over time?
- What workup has been done and what were the results (prior ultrasound, CT, CA-125)?
Quick Reference: ACOG Referral Criteria to Include in Documentation
From Schwartz's Principles of Surgery - document whether any of these are present, as they trigger oncology referral:
| Premenopausal Women | Postmenopausal Women |
|---|---|
| CA-125 > 200 U/mL | Any elevated CA-125 |
| Ascites | Ascites |
| Evidence of metastasis | Nodular or fixed pelvic mass |
| Family history: 1st-degree relative with ovarian or breast cancer | Family history: 1st-degree relative with ovarian or breast cancer |
| Evidence of abdominal or distant metastasis |
Summary Template for HPI (Adnexal Neoplasm)
"Ms. [X], a [age]-year-old [pre/postmenopausal] woman, presents with a [incidentally discovered / symptomatic] adnexal mass. She reports [onset] of [pelvic pain, bloating, early satiety, urinary frequency - specify which]. Pain is [character, location, severity, duration]. LMP was [date]. She has [+/-] dysmenorrhea, dyspareunia, abnormal bleeding. Menstrual cycles are [regular/irregular]. She is [gravida X, para X]. She [has/has no] personal or family history of ovarian, breast, endometrial, or colorectal cancer. BRCA status: [known/unknown]. Prior OCP use: [yes/no/duration]. Relevant prior surgeries: [list]. Prior imaging: [describe prior ultrasound or CT findings and date]. She [does/does not] report constitutional symptoms."
Sources:
- Berek & Novak's Gynecology, Chapter 10 - Diagnosis of Postmenopausal Pelvic Mass, p. 485-486
- Schwartz's Principles of Surgery, 11th Ed., Chapter 41 - Ovarian Cancer, p. 1843
- Textbook of Family Medicine, 9th Ed., Chapter 25 - Pelvic Mass, p. 618
- Creasy & Resnik's Maternal-Fetal Medicine - Adnexal Mass, Complex and Simple
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