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Hospital Discharge Report
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Synthesis
Voluntary surgical sterilization, procedure completed
Hospital course note
Dear colleague, I am writing to inform you regarding your patient, an 81-year-old
female who was admitted on 12th April 1976 at her own request for elective surgical
sterilization. Pre-operative assessment including routine blood work, cardiovascular
evaluation, and anaesthetic review was performed and found satisfactory given her
age. The patient was counselled extensively regarding the permanent nature of the
procedure, and informed consent was duly obtained. She subsequently underwent bilateral
tubal ligation under general anaesthesia without intraoperative or postoperative complications.
Recovery was uneventful, and she was mobilised and tolerating diet well prior to discharge
on 13th April 1976. Wound inspection revealed satisfactory healing. She has been advised
regarding postoperative care and warning signs. No further gynaecological follow-up
is anticipated unless concerns arise. Please do not hesitate to contact us should
you require further information.
Diagnosis at Discharge
| Sterilization admitted | 13-Apr-1976 | active |
Significant procedures
| General anaesthesia | 13-Apr-1976 | - |