Medical Discharge Letter
[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:
Community-Acquired Pneumonia
Mild Dehydration
Treatment Provided:
During Mr. Doe’s hospitalization, the following treatments were administered:
Intravenous (IV) antibiotics – Ceftriaxone 2g daily for 5 days.
IV fluids – Normal Saline 1000 ml twice daily for 3 days to manage dehydration.
Symptomatic treatment – Paracetamol 500mg for fever as needed.
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:
Amoxicillin-Clavulanic Acid 625mg – 1 tablet every 8 hours for 7 days.
Paracetamol 500mg – 1 tablet as needed for fever, not exceeding 4 tablets per day.
Multivitamin Supplements – 1 tablet daily for 14 days.
Post-Discharge Instructions:
Follow-Up Appointment: 3 July 2050 at 10:00 AM, Pulmonology Department.
Lifestyle Recommendations:
Complete rest for 7 days.
Increase fluid intake (at least 2 liters/day).
Avoid strenuous activities.
Warning Signs to Monitor:
Persistent fever beyond 3 days.
Worsening cough or shortness of breath.
Chest pain or unusual fatigue.
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
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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