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Hospital Discharge Report
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Synthesis
Acute appendicitis, appendectomy performed
Hospital course note
Dear colleague, I am writing to inform you about the hospital course of your patient,
a 56-year-old male, admitted on 30/04/2019 with acute right lower quadrant abdominal
pain, nausea, and low-grade fever, clinically suspicious for appendicitis. On admission,
laboratory findings revealed leukocytosis (WBC 14.2 × 10³/µL) with elevated CRP. Abdominal
ultrasound confirmed an inflamed, non-perforated appendix. A subsequent CT scan of
the abdomen corroborated the diagnosis of acute appendicitis without perforation or
abscess formation. The patient underwent uncomplicated laparoscopic appendectomy on
01/05/2019 under general anaesthesia. Postoperative recovery was uneventful. Antibiotic
prophylaxis was administered perioperatively. The patient was mobilised on postoperative
day one and discharged home on 02/05/2019 in good general condition. Wound healing
was satisfactory. Please arrange follow-up in approximately two weeks. Should you
have any questions, please do not hesitate to contact me.
Diagnosis at Discharge
| Unspecified appendicitis | 02-May-2019 | active |
Significant procedures
| Excision of appendix (procedure) | 30-Apr-2019 | - |