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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 31-year-old female,
admitted on 08/09/2000 with acute right lower quadrant abdominal pain, nausea, and
low-grade fever. Clinical examination revealed marked tenderness at McBurney's point
with positive rebound tenderness. Laboratory findings demonstrated elevated leukocytosis,
and abdominal ultrasound confirmed appendiceal inflammation consistent with acute
appendicitis. The patient underwent an uncomplicated laparoscopic appendectomy on
09/09/2000. Histopathological examination confirmed acute appendicitis without perforation.
Postoperative recovery was uneventful. The patient was administered intravenous antibiotics
perioperatively and adequate analgesia throughout her stay. She was discharged home
on 12/09/2000 in good clinical condition with oral analgesia and wound care instructions.
Please arrange follow-up in 2 weeks for wound inspection and review of histology results.
Do not hesitate to contact me if further information is required.
Diagnosis at Discharge
| Unspecified appendicitis | 12-Sep-2000 | active |
Significant procedures
| Wound dressing change | 10-Sep-2000 | - |