Sample Narrative Report In Malaysia

DEMOGRAPHIC DETAILS

Name: Madam SY

Age: 29 years old

Ethnic Group: Malay

Occupation: Primary School Teacher

R/N: SB 00442720

Date of admission: 21st of July 2016

Date of discharge : -

GENERAL REPRODUCTIVE HISTORY

 Parity 3

 Day 1 post vaginal delivery

 Last menstrual period (LMP): Not sure of LMP. Hence, ultrasound scan was done at 10 weeks period of gestation during her booking.

PRESENTING COMPLAINT(S)

Madam SY, a 29 year old Malay Primary School Teacher, Parity 3, day 1 post vaginal delivery was admitted to referred to Hospital Sungai Buloh from Tanjung Karang a day ago which she was 39 weeks+3 days period of gestations with chief complaint of reduce in fetal movement. She was unsure of her last menstrual period. Thus, Ultrasound scan

In the labour room, CTG was done and it was confirmed that fetal was in bradycardia. During that time, she started to have abdominal pain and abdominal contractions once lasting for about 40-60 seconds for every 30 minutes. Bimanual vaginal examination was done and cervical dilatation was about 3 cm. There was also leaking liquo at that moment but not in a significant amount. Actually, when she arrived in the labour room, she was already in latent phase of stage 1 labour and was inserted with branula over dorsum of right hand which was connected to Hartmann's solution

It was sutured smoothly and no excessive bleeding occurred throughout the delivery.

She delivered a baby girl vaginally which weighs about 3.1kg at 3.10am a day ago.

POST NATAL HISTORY

Madam SY was examined a day after her delivery. she was afebrile with normal vital signs. She had odourless per vaginal discharge with blood of red in colour (Lochia rubra). She had used about 2 maxi pad fully soaked. She still had pain over the suture site but no bleeding and no other discharge. She could ambulate well and able to pass urine but no bowel opening yet. She had no problem to breastfeed her daughter with all the experience she had from her first and second child. She was fully rested and was not lethargic. She denied of anaemic symptoms such as shortness of breath, palpitation, syncope, dizziness and blurred of vision. She did not look pale.

Baby : She breastfed her baby more than 7 times in 24 hours. Her daughter weighed about 3.1kg and had passed her urine and bowel opening within 24 hours of life.

ANTE-NATAL CONDITION

1st trimester (1-12 weeks)

 Her pre pregnancy weight was 52 kg and height of 155 cm. Her BMI was