Medical Discharge Letter

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[Your Company Name]
[Your Company Address]
[Your Company Number]
[Your Company Email]

Date: 26 June 2050

To Whom It May Concern,

Re: Medical Discharge Summary
Patient Name: Mr. John Doe
Date of Birth: 15 March 1985
Hospital Admission Date: 20 June 2050
Hospital Discharge Date: 26 June 2050
Medical Record Number: CH-56789

Diagnosis:

1. Community-Acquired Pneumonia

2. Mild Dehydration

Treatment Provided:
During Mr. Doe’s hospitalization, the following treatments were administered:

1. Intravenous (IV) antibiotics – Ceftriaxone 2g daily for 5 days.

2. IV fluids – Normal Saline 1000 ml twice daily for 3 days to manage dehydration.

3. Symptomatic treatment – Paracetamol 500mg for fever as needed.

4. Chest physiotherapy to aid with breathing recovery.

Course in Hospital:
Mr. Doe was admitted with complaints of high-grade fever, persistent cough, and shortness of breath. Upon admission, clinical assessment and imaging confirmed pneumonia. IV antibiotics and supportive treatment were initiated promptly. His condition gradually improved, with a significant reduction in fever and respiratory distress. By discharge, his vital signs were stable, and his general condition was satisfactory.

Discharge Medications:

1. Amoxicillin-Clavulanic Acid 625mg – 1 tablet every 8 hours for 7 days.

2. Paracetamol 500mg – 1 tablet as needed for fever, not exceeding 4 tablets per day.

3. Multivitamin Supplements – 1 tablet daily for 14 days.

Post-Discharge Instructions:

1. Follow-Up Appointment: 3 July 2050 at 10:00 AM, Pulmonology Department.

2. Lifestyle Recommendations:

   • Complete rest for 7 days.

   • Increase fluid intake (at least 2 liters/day).

   • Avoid strenuous activities.

3. Warning Signs to Monitor:

   • Persistent fever beyond 3 days.

   • Worsening cough or shortness of breath.

   • Chest pain or unusual fatigue.

4. Contact the hospital immediately in case of the above symptoms or any new complications.

Prognosis:
Mr. John Doe has shown significant improvement during his stay. He is stable and fit for discharge. Full recovery is anticipated with compliance to the prescribed treatment plan and post-discharge care.

Authorized By:

Dr. Sarah Thompson, MD
Attending Physician, Pulmonology Department
[Your Company Name]
Phone: (123) 456-7890 ext. 221

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Patient/Guardian Acknowledgment:
I have received the discharge instructions and medications as listed above.

Signature:                                
Name: Mr. Mark Doe
Date: 26 June 2050

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