COPD Discharge Letter for Sian Steward

[Hospital/Clinic Letterhead]
Date: December 2, 2025
Patient Name: Sian Steward
Date of Birth: 14/05/1962
Hospital Number: H6789012A
Discharge Date: 02/12/2025
Attending Consultant: Dr. Eleanor Vance, Respiratory Medicine
Ward: Chest Unit 4B
GP Name and Address: Dr. John Smith, City Health Practice, 12 Main Street, Anytown, UK

Discharge Summary

Primary Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) - Acute Infective Exacerbation
Admission Date: 28/11/2025
Reason for Admission: Worsening shortness of breath, increased cough, and change in sputum color/volume, consistent with an acute infective exacerbation of COPD.

Key Investigations:
Chest X-ray: No acute consolidation or pleural effusion; mild hyperinflation noted.
Arterial Blood Gas (ABG): Improved respiratory acidosis (pH 7.38, PaCO2 6.1 kPa on discharge).
Sputum Culture: Grown Haemophilus influenzae, sensitive to co-amoxiclav.

Treatment during Admission:
Intravenous Co-Amoxiclav for 3 days, transitioned to oral for a total course of 7 days.
Increased frequency and dose of nebulized bronchodilators (Salbutamol, Ipratropium).
Oral corticosteroids (Prednisolone 40mg once daily) for 5 days.
Chest physiotherapy and breathing exercises provided.
Maintenance oxygen discontinued; patient stable on room air.

Discharge Medications

Medication | Dose | Frequency | Route | Duration/Notes
Inhaler 1 (LABA/LAMA/ICS) Fostair Nexthaler (200/6) | 1 puff | Twice Daily | Continue as usual
Inhaler 2 (SABA - Reliever) Salbutamol (100mcg) | PRN (as needed) | As required | Use for sudden shortness of breath. Max 8 doses/day
Antibiotics Co-Amoxiclav (625mg) | Twice Daily | Oral | Complete the full 7-day course (last dose 04/12/2025).
Oral Prednisolone 5mg | Once Daily | Oral | To be stopped after a further 3 days (total course complete).
Other Regular Meds Atorvastatin 20mg | Once Daily | Oral | Continue all usual medications.

Note to GP: Please check the patient's updated electronic prescribing record for the most accurate and complete list of medications.

Follow-up & Key Advice

1. Relapse Prevention & Action Plan
COPD Rescue Pack: Ms. Steward has been discharged with an agreed-upon Personalised COPD Action Plan and a Rescue Pack containing:
Oral Prednisolone (30mg tablets - 5 days supply)
A course of Amoxicillin (or alternate antibiotic, based on current guidelines/allergies)

Patient Education: Ms. Steward understands that she should start the rescue pack if she experiences two or more of the following for 24 hours:
Worsening breathlessness that doesn't improve with her reliever inhaler.
Increased volume of sputum.
Change in sputum color (e.g., yellow, green, or rusty).

2. Referral & Follow-up Appointments
Pulmonary Rehabilitation: Referral placed for the local Pulmonary Rehabilitation Programme (starts week commencing 15/12/2025).
COPD Nurse Specialist: Follow-up appointment arranged for 09/12/2025 at 10:00, Outpatient Clinic 2.
GP Review: Routine review with the GP requested within 3 working days (by 05/12/2025) to check on stability and review the COPD action plan.

3. Lifestyle Advice
Smoking Cessation: Ms. Steward has been strongly advised to abstain from smoking. Referral to the local cessation service has been completed and she has agreed to attend the first appointment on 08/12/2025.
Inhaler Technique: Technique checked and confirmed to be correct before discharge.
Vaccinations: Ensure annual Flu vaccine and 5-yearly Pneumococcal vaccine are up to date (Flu received 10/2025; Pneumococcal due 2027).

Summary of Discharge Status: Ms. Steward is clinically stable, mobilizing well, and managing her symptoms with oral medications and inhalers. She understands her personalised COPD action plan and when to seek urgent medical attention.

Signed:
[Signature]
Dr. Alex Chen, Junior Doctor
On behalf of Dr. Eleanor Vance, Respiratory Medicine
Contact Number (for queries): 0123-456-789 (Bleep 1234)

Action for GP
Review and confirm all discharge medications, including the continuation/taper of corticosteroids.
Ensure the patient has a copy of and understands the Personalised COPD Action Plan.
Arrange a review appointment within 3 working days.
