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Hospital Discharge Report

Patient
Name: Breton, Alex
DOB: 01-OCT-1998 (Age: 27)
Gender: female
ID: 2780-054365-7
Author
Samson, Martin
Hospital Discharge Report
Report Date: 08-DEC-2020
Hospital Admission: --
Hospital Discharge: --

Synthesis

Voluntary surgical sterilization, procedure completed

Hospital course note

Dear colleague, I am writing to inform you regarding your patient, a 26-year-old female who was admitted on 07.12.2020 at her own request for elective surgical sterilization. Prior to the procedure, a thorough gynaecological assessment was performed, including review of her medical history, physical examination, and routine preoperative laboratory workup, confirming no contraindications to surgery. The patient was counselled extensively regarding the permanent nature of the procedure and provided informed written consent. On 07.12.2020, bilateral laparoscopic tubal ligation was performed under general anaesthesia without intraoperative or postoperative complications. Recovery was uneventful, and the patient was discharged home on 08.12.2020 in good general condition. No further gynaecological follow-up is specifically required unless the patient develops concerns. Please continue routine primary care management.

Diagnosis at Discharge

Sterilization admitted 08-Dec-2020 active

    Significant procedures

    Ligation of bilateral fallopian tubes (procedure) 07-Dec-2020 -