Discharge Summary

OPD IPD Emergency Radiology LIS Pharmacy

Finalized

Admission

IPD-2026-04471, Ward 3B, Bed 12 — admitted 2026-08-09

Discharge Date

2026-08-13

Reason for Admission: Fever, productive cough, and breathlessness for 4 days.
History: No prior hospitalization. Non-smoker. No known comorbidities.
Examination: On admission: RR 26/min, SpO₂ 91% on room air, right basal crackles on auscultation.
Investigations: Chest X-Ray: right lower lobe consolidation. WBC 14.2 ×10⁹/L (High). CRP 68 mg/L (High).
Diagnosis: Community-Acquired Pneumonia (right lower lobe)
Treatment: IV Ceftriaxone 1g OD × 5 days, then oral Amoxicillin-Clavulanate to complete 7 days. Supplemental oxygen 2L/min via nasal cannula, weaned by Day 3. Chest physiotherapy.
Procedures: None
Clinical Course: Steady clinical improvement. Afebrile from Day 3. SpO₂ normalized to 98% on room air by Day 4. Tolerating oral diet and mobilizing independently.
Condition at Discharge: Stable, afebrile, SpO₂ 98% on room air.
Discharge Medications: Amoxicillin-Clavulanate 625mg TID for 2 more days (complete 7-day course).
Follow-up: OPD Follow-up — General Medicine, 2026-08-20, Dr. Wei Zhang.
Advice: Complete the full antibiotic course. Return immediately if fever, breathlessness, or chest pain recur. Adequate rest and hydration.