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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 regarding your patient, a 40-year-old female,
admitted on 20/08/1987 with acute right iliac fossa pain, nausea, and low-grade fever.
Clinical examination revealed rebound tenderness at McBurney's point. Laboratory investigations
confirmed leukocytosis, and abdominal ultrasound supported the diagnosis of acute
appendicitis. The patient underwent an uncomplicated open appendectomy on 21/08/1987.
Histopathological examination confirmed acute appendicitis. Postoperative recovery
was uneventful. The patient received perioperative antibiotic prophylaxis and adequate
analgesia. She was mobilised early and tolerated oral intake well. Wound healing was
satisfactory at discharge on 23/08/1987. Please ensure appropriate wound care and
suture removal in approximately 10 days. Return to normal activities expected within
4–6 weeks. Please do not hesitate to contact us should any concerns arise.
Diagnosis at Discharge
| Unspecified appendicitis | 23-Aug-1987 | active |
Significant procedures
| Postoperative analgesia administration | 21-Aug-1987 | - |