How to report the case

Thank you for the opportunity.

I would like to report 1 case of Mrs........
S (Subjective) :
Mrs/Ms .... years old, (Parity...Abortion....) referred from .... hospital or referred by dr......... on ......with the
diagnosis of......
She was admitted to Hospital with the chief complaints of...............(abdominal enlargement, vaginal
bleeding, etc..)
She had been having the complaints from 2 days ago
The complaints are accompanied by pelvic pain
She had already been currettaged by dr.......
She denied about having DM, Asthma, hypertension.......
Previously she had visited a healer (psychic = dukun) and her abdomen was massaged.
She had her menarche at the age of....
The patient had ever been admitted to the hospital on.......before........
She had progressively decreasing body weight / decreasing body weight is approximately.......

She couldn’t move her legs and she was just lying in bed.
Age of first marital age = umur pertama kali menikah
She was married at the age of......
She has been using pill all this time or she had used pill before
She has never used contraception/she has never been using contraception
Failed to perform daily activity normally
The patient planned to be given transfusion
She is able to perform micturition and defecation well enough /bit by bit micturition / gradual micturition

O (Objective):
The general condition of the patient now is anemic and weak.
Vital signs:
BP (Blood Pressure) = ....
HR (Heart rate) = .....
T (Temperature) = .....
RR (Respiratory rate) = ....

Physical Examination:
General condition = mild sickness/sufficient nutrition/conscious
Inspection:
Conjunctiva = anemic; no anemic found
Sclera = any icterus?
CVP = wnl (within normal limit)
Breast = symmetrical/asymmetrical. The nipple = retraction / no retraction / hyperpigmentation / discharge
from the nipple
Heart sound = wnl/murmur
Breath sound = vesicular/bronchovesicular/wheezing/ronchi in the basal of lung or in the apex of lung

Abdomen:
From inspection it is found the abdomen seems convex in shape/ flat/concave.
There is a cystic mass whose size is......./ no mass found
From palpation it is observed that liver not enlarging/liver palpable untill 2 fingers down the XII th ribs. The
spleen not palpable or palpable.
Mass is palpated in the right/left lumbal region/inguinal region with the size of 12 x 15 x 20 cm,
mobile/movable. The patients feel pain during palpation.
Gynecologic examination
From inspection of vulva it is found that no abnormality, no mass, no ulcer/ some mass found with the
size of 2 x 3 cm with bleeding occurring.
Out of the mass palpation, cystic/solid, mobile and pain is observed
From inspeculo we find the cervix was normal/some bleeding coming out of the OUE/some discharge out
of the OUE. The surface of the portio was smooth/non flat/nodular. The size of the cervix was 4 x 4 x 2
cm.
From Vaginal examination
The position of the uterus was anteflexi/retroflexi. Its size is examplified as adult’s fist/baby’s head/pear
fruit/Balinese orange of 9 x 5 cm. No pain is found.
The adnexa was normal with no pain or there is mass palpable of 9 x 6 x 4 cm size.
From rectal examination
TSA was normal or tightening, smooth mucous, empty ampulla, palpable mass before rectum.

Working diagnosis: ......Solid ovarian neoplasm suspected malignancy or Cystic Neoplasm suspected
malignancy.

Supporting examination: the patient had completed the supporting examination

Ultrasound : uterus is normal, anteflexion, and the size is within normal limit (wnl). There is a mass found
with the size of 20 x 15 x 12 cm, hyperechoic/hypoechoic or some hyperechoic and some other
hypoechoic. The border of the tumor is well-defined/not well-defined. There is feature of papillary growth
inside the tumor. Ascites dominate the abdominopelvic cavity. The Resistance Index (RI) is 0.3 (lower
than 0.4). Both kidneys are wnl / show enlargement of pelviocalyces system (PCS).

Colposcopy: The Squamocolumnar junction (SCJ) is completely noticed. White epithelium is observed at
the direction of 9 o’clock, clearly white, blurredly white in colour with irregular edges.

CBC (Complete Blood Count)

CXR (Chest X Ray)

Diagnosis

Management

Follow up

It would be wiser not to have her operated = causative sentence

When was she performed operation.....
You even worsen the disease
I don’t dare to state......
It doesn’t necessarily indicate.....