CityCare Multispeciality Hospital
14, Ring Road, Lajpat Nagar, New Delhi
Delhi — 110024
Ph: +91-11-4567-8900 · ipd@citycare.in
Allopathy · MBBS · Reg MMC-2012-04567
Clinical Reg DL-CE-2019-04412
Dr. A. Khan
Allopathy Discharge Summary
No: DIS/25-26/000198
Dt: 23-09-2026 11:00
Allopathy Discharge · Dr. A. Khan · MBBS · Reg MMC-2012-04567
Patient
Ramesh Gupta · 54 Y · M
UHID: UHID-2024-118822
Admitted: 20-09-2026 09:30 (IPD/25-26/000214)
Discharged: 23-09-2026 11:00
Ph: +91-98110-22334
Diagnosis
Community-acquired pneumonia (right lower lobe) with T2DM
ICD-10: J18.1
Condition: Afebrile 48 hrs; SpO2 96% room air; productive cough resolving; walking unassisted.
Course in hospital
Treatment: Community-acquired pneumonia treated with IV Ceftriaxone 1 GM BD × 3 days; switched to oral Amoxycillin-Clavulanate after 48 hrs afebrile. Supportive O2, physiotherapy and glycemic control.
Procedures: IV cannula (removed 23-09); twice-daily glucose monitoring; chest physiotherapy sessions; urinary output chart.
IV Ceftriaxone 1 GM BD (3 days): 20-09-2026 to 22-09-2026 — Afebrile from day 2
O2 by nasal prongs 2 L/min, tapered to room air: 20-09-2026 to 22-09-2026 — SpO2 96% room air from 22-09
Investigations: Chest X-ray (PA) — right lower-lobe consolidation; CBC, CRP, RFT, daily capillary glucose chart; Blood culture — no growth at 48 hrs; Sputum Gram stain
Discharge medicines
| Sl | Medicine (Generic / Brand) | Dose / Route | Freq | Duration |
|---|---|---|---|---|
| 1 | Moxikind-CV 625TABAMOXYCILLIN + CLAVULANATE · 625 MGComplete the full course — no early stop | 1 TABOral | BD (1-0-1) | 5 DAYS |
| 2 | Glycomet 500TABMETFORMIN · 500 MGAfter food; resume home dose | 1 TABOral | BD (1-0-1) | 30 DAYS |
| 3 | Dolo 650TABPARACETAMOL · 650 MGOnly if fever or pain returns | 1 TABOral | SOS (0-0-1) | 3 DAYS |
Diet advice
Diabetic diet, no added sugar; high-protein (dal, eggs, paneer); 8–10 glasses of water daily.
Activity advice
Walk 10 min every 2 hrs indoors; no heavy lifting for 2 weeks; breathing exercises 3× daily for 1 week.
Follow-up: 30-09-2026
Red flags — report immediately: Fever recurrence, breathlessness at rest, chest pain, coughing blood, confusion or drowsiness.
Emergency: +91-11-4567-8900 (24×7 casualty)