Harsh
Patient ID
UHID-2026-001
Age / Gender
45 yrs / male
Department
Surgery
Discharge Type
routine
Admission Date
10/07/2026
Discharge Date
14/07/2026
Reason for Admission
Three-day history of right lower abdominal pain, fever, and vomiting.
Presenting Complaints
Right lower abdominal pain, fever, and vomiting.
Admitting Diagnosis
Acute appendicitis.
Hospital Course
The patient was admitted with a three-day history of right lower abdominal pain, fever, and vomiting. On admission, she was diagnosed with acute appendicitis. She underwent an emergency laparoscopic appendectomy under general anesthesia on the day of admission. Postoperatively, she remained hemodynamically stable and was started on intravenous antibiotics for two days. She made an uneventful recovery. Blood investigations showed an elevated white cell count of 18,000 on admission, which normalized by day three.
Procedures Performed
Emergency laparoscopic appendectomy under general anesthesia.
Investigations Summary
Blood investigations showed an elevated white cell count of 18,000 on admission, which normalized by day three.
Final Diagnosis
Acute appendicitis, status post laparoscopic appendectomy.
Discharge Medications
| Medication | Dosage | Route | Frequency | Duration | Instructions |
|---|---|---|---|---|---|
| Numetins | 625 milligram | oral | twice daily | for five days | — |
| Paracetamol | 650 milligrams | oral | as needed for pain | for three days | — |
Condition at Discharge
Stable, afebrile, tolerating oral diet, wound healing well.
Vitals at Discharge
Blood Pressure
120/80
Pulse Rate
76
Temperature
98.6 Fahrenheit
Respiratory Rate
—
SpO2
99%
Weight
—
Allergies
No known drug allergies.
Discharge Instructions
Diet: Progress diet from clear liquids to a regular diet as tolerated; avoid heavy or oily food for the first week.
Activity: Avoid heavy lifting (>5 kg) and driving for 2 weeks. Gentle walking is encouraged to prevent complications.
Wound Care: Keep the surgical wound clean and dry. Watch for redness, swelling, discharge, or fever, and do not remove dressings without medical advice.
Seek Emergency Care If: Return immediately for wound bleeding or discharge, fever, severe abdominal pain, or inability to pass urine or stool.
Follow-up: Follow up in 7–10 days for suture/wound review, or sooner if any warning signs develop.
Digital Signature
Signed by Dr. Priya Sharma • MCI-2024-00123
Raw Transcription
The patient was admitted with a three-day history of right lower abdominal pain, fever, and vomiting. On admission, she was diagnosed with acute appendicitis. She underwent an emergency laparoscopic appendectomy under general anesthesia on the day of the admission. Postoperatively, she remained hemodynamically stable, was started on intervention antibiotics for two days and made an uneventful recovery. Blood investigations showed an elevated white cell count of 18,000 and on admission, which normalized by day three. Final diagnosis is acute appendicitis, status post laparoscopic appendectomy. She had no known drug allergies. She is being discharged on tablet Numetins 625 milligram oral twice daily for five days and tablet Paracetamol 650 milligrams oral as needed for pain for three days. At discharge, her condition is stable, afebrile, tolerating oral diet, wound healing well. Blood pressure 120 over 80 plus 76 temperature 98.6 Fahrenheit oxygen saturation 99%.