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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 male,
admitted on 27th February 1995 with acute right iliac fossa pain, nausea, and low-grade
fever. Clinical examination revealed rebound tenderness at McBurney's point. Laboratory
investigations confirmed elevated white cell count and CRP consistent with acute appendicitis.
Abdominal ultrasound supported the diagnosis. The patient underwent an uncomplicated
open appendectomy on 27th February 1995 under general anaesthesia. Histopathological
examination confirmed acute appendicitis. Postoperative recovery was uneventful. Analgesia
and intravenous antibiotics were administered perioperatively. The patient was discharged
home on 28th February 1995 in good condition. Please arrange wound review in approximately
one week and ensure appropriate analgesia is prescribed. Should any concerns arise,
please do not hesitate to contact our surgical department.
Diagnosis at Discharge
| Unspecified appendicitis | 28-Feb-1995 | active |
Significant procedures
| Wound care and dressing | 28-Feb-1995 | - |