Harsh
Patient ID
UHID-2026-001
Age / Gender
45 yrs / male
Department
Surgery
Discharge Type
routine
Admission Date
14/07/2026
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 for three days.
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 procedure under general anesthesia on the day of admission. Post-operatively, she remained hemodynamically stable, was started on intervation antibiotics for two days, and made an uneventful recovery. Blood investigations showed an elevated white cell count of 18,000 on admission, which normalized by three days.
Procedures Performed
Emergency laparoscopic appendectomy under general anesthesia on the day of admission.
Investigations Summary
Blood investigations showed an elevated white cell count of 18,000 on admission, which normalized by three days.
Final Diagnosis
Acute appendicitis, status post laparoscopic appendectomy.
Discharge Medications
| Medication | Dosage | Route | Frequency | Duration | Instructions |
|---|---|---|---|---|---|
| Augmentin | 625 mg | oral | twice daily | 5 days | — |
| Paracetamol | 650 mg | oral | as needed | 3 days | for pain |
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 three day history of right lower abdominal pain, fever and vomiting on admission she was diagnosed with a acute appendicitis. She underneath an emergency laparoscopic under general anesthesia on the day of the admission post operatively she remained hemodynamically stable was started an intervation antibiotics for two days and made an uneventful recovery. Blood investigation showed an elevated white cell count of 18,000 on admission which normalized by three days. Finally final diagnosis is acute appendicitis status post laparoscopic appendectomy. She has no known drugs allergies she is been discharged on tablet augmentin 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 120/80, pulse 76, temperature 98.6 Fahrenheit, oxygen saturation 99%.