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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 73-year-old
male patient, admitted on 04/03/1995 with acute right lower quadrant abdominal pain,
nausea, and low-grade fever, clinically suspicious for appendicitis. Diagnostic workup
including laboratory analysis revealing leukocytosis and CRP elevation, alongside
abdominal ultrasound and CT imaging, confirmed acute appendicitis without perforation.
The patient underwent an uncomplicated open appendectomy under general anaesthesia
on 05/03/1995. Postoperative recovery was uneventful. Wound healing was satisfactory,
inflammatory markers normalised, and the patient was mobilised successfully. He was
discharged home on 07/03/1995 in stable condition with oral analgesia and wound care
instructions. Histopathology of the appendix specimen is pending; results will be
forwarded upon receipt. Please arrange follow-up in approximately two weeks.
Diagnosis at Discharge
| Unspecified appendicitis | 07-Mar-1995 | active |
Significant procedures
| Wound dressing and care | 06-Mar-1995 | - |