CLINIC VISIT REPORT

Maneessa Mahendran
00000014504
Intake : ME 2/14
Klinik Komuniti Cheras Baru
Date of Visit : 26th of March 2015

1. Personal Details
Name : Kalaivelan
Age : 20 years old
Gender : Female
Race : Indian
2. Chief Complaint : Stomach pain, has been ongoing for 2 days
3. History of Presenting Illness
The stomach pain was described as sharp and it disrupted her sleep.
She also could not eat properly. There was no radiation of the pain, as well
as no associated symptoms. The pain was constant throughout the day, but
worsened at night. She tried taking gastric pills but it gave no relief. This is
the first time this occurred. History of previous illnesses includes a stroke
last year. No history of diabetes or hypertension. She has not undergone any
surgery. She is still working as a cashier at a nearby supermarket, despite the
pain. She smokes an estimate of one pack of cigarettes a week. She also
drinks alcohol, but only once in a while.
4. Family History
- Only she is suffering from this pain
- None of her family members have diabetes mellitus
- None of her family members suffer from hypertension