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Hospital Discharge Report
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Synthesis
Rotator cuff repair performed, post-operative recovery uneventful
Hospital course note
Dear colleague, I am writing to inform you regarding your patient, a 40-year-old male,
admitted on 23/04/2019 following confirmed injury to the rotator cuff of the right
shoulder. Clinical examination revealed significant pain, reduced range of motion,
and weakness on abduction. MRI confirmed a full-thickness rotator cuff tear involving
the supraspinatus tendon. Following multidisciplinary assessment, the patient underwent
arthroscopic rotator cuff repair on 25/04/2019. Post-operative recovery was uneventful,
with adequate pain management achieved using analgesics and physiotherapy initiated
prior to discharge. Wound healing was satisfactory. The patient was discharged on
29/04/2019 with a sling, oral analgesia, and referral for outpatient physiotherapy.
Please ensure follow-up within two weeks and monitor for signs of re-tear or infection.
Should you require further information, do not hesitate to contact our department.
Diagnosis at Discharge
| Rotator cuff syndrome | 29-Apr-2019 | active |
Significant procedures
| Surgical manipulation of shoulder joint (procedure) | 23-Apr-2019 | - |