1822708090出院小結(jié)英文5篇

1、-最新精品資料推薦-提供全程指導服務(wù)- 出院小結(jié)英文5篇 discharge record patient id:0168220 name: xxxx age:73-y-o sex: male/female admission date: xxxx operation date: xxxx discharge date: xxxx diagnosis: acute myocardial infraction rca completely blocked lca has a 50% leision in the proximal and lad has 30-50% leisions type

2、2 diabetes mellitus( 2-dm). admission: sudden chest pain for 4 hours patient history: 73-year-old man without significant heart problems presented with sudden chest pain for 4 hours. and the pain constantly radiated to the shoulder and back.the electrocardiogram(ecg) of the patient showed the st seg

3、ment of the leads ,avf raised 0.1-0.2 mv and was admitted for further evaluation and treatment cardiovascular riskfactors: 2-dm, fat physical examination: blood pressure 120/60mmhg, pulse 60/minute.the lungs were clear. the heart rate was regular, 60 beats per minute. no murmur and pericardial rub w

4、as heard. the abdomen was unremarkable. there was no peripheral edema. laboratory results: hb: 133g/l glucose: 8.6 mmol/l( chol: 4.68mmol/l tg: 0.86 mmol/l ldl-c: 3.07 mmol/l hdl: 1.11 mmol/l crp: 8.60mg/l (0-8 mg/l) ck-mb: 299.2 u/l (0-16 u/l) troponin i: 0.24ng/ml ( ecg: a normal rhythm at rate of

5、 60/minute, st segment raised 0.1-0.2 mv in leads ,avf. transthoracic echocardiogram(tte):the size of left atrium is 41.2mm and the other chambers were normal.ef:51% cag: the middle of right coronary artery(rca) completely blocked and left coronary artery (lca) has a 50% leision in the proximal and

6、left anterior descending(lad) has some 30-50% leisions. after admission, we implant one stent.(3.5/15 mm) in the rca. treatment: after operation, trearment was started for the recovery .it was treated with aspirin 100mg po qd , plavix 75mg po qd, dilatrend 6.25mg bid, imdur 60mg qd, and clexane(low-

7、molecular-weight heparins sodium)5000 usc q12h. after 16 days of recovery , the patient is well. so we think the patient can discharge hospital. medication: 1.medicines to improve heart function and their uses aspirin 100mg po 1-0-0 plavix 75mg po 1-0-0 for 9 months zocor(statin) 40mg po 0-0-1 micar

8、dis 40mg po 1-0-0 spironolactone 20mg po 1-0-0 dilatrend 6.25mg po 1-0-1 2.medicines to control blood sugar and their uses glargine(insulin) 34u ih 1-0-0 glucobay 50mg po 1-1-1 avandia 8mg po 1-0-0 comments: 1. no smoking and drinking and keep diet 2. strictly controll blood sugar 3. be attention to

9、 keep rest and do not do high-intensity exercises 4. eat medicines on time and follow-up visit after one month. dotor: xxxxxx2英文出院小結(jié) 姓名 zhao xx 性別 male 年齡 51 入院診斷 acute pancreatitis 簡要病史、體格檢查和入院輔助檢查 complaints:”left upper abdominal pain for 1 day.” alcohol triggered. severe, constant pain with nause

10、a & vomiting. more intense when supine, but relieved by staying with the trunk flexed and knees drawn up. no radiation. no abdominal distention. no gallstone history. physical examination: low-grade fever. normal to elevated bp. distressed, anxious. jaundice(-). moderate abdominal tenderness, with n

11、o muscle rigidity. laboratory data: serum amylase,serum lipase,urine amylase,white blood cells, plasma glucose. ct plaint scan: no indicative sign. gastroduodenal endoscopy: inflammatory changes, no ulcer observed. etc. 治療經(jīng)過：fasting. intravenous fluids. nutritional support. nasogastric suction. prop

12、hylactic antibiotic. inhibiting pancreatic secretion. others including consultations. 出院轉(zhuǎn)歸：resolution of abdominal pain 出院診斷：acute pancreatitis 出院醫(yī)囑：avoidance of alcohol. fluid diet gradually to regular diet. symptoms observation. hospitalization when necessary.3英文出院小結(jié) dicharge summary discharge dia

13、gnosis 1. unstable angina. 2. multi-vessel artery diease 3. hyperlipidema reason for admission mr.zhou is a 69-year-old chinese man who is actually a native of beshing and in the united states visiting his daughter. he presented to the heart hospital emergency room with substernal discomfort radiati

14、ng to the arm. there was mild improvement with nitroglycerin. he had discomfort on and off over a two-day period. he was admitted for further management. hospital course mr.zhou ruled out for a myocardial infarction by serial enzymes. an adenosine cardiolite stress was performed. this showed anterio

15、r and inferior ischemia. caridiac catheterization was then performed by dr. picone. coronary arteriography revealed a subtotal proximal lad followed by total occlusion mid vessel. the distal lad filled via collaterals from the circumflex and looked small and diffusely diseased. the circumflex was pa

16、tent. there was a 50 percent stenosis in the obtuse marginal. the right coronary artery had a 75 percent mid vessel stenosis and a 100 percent distal occlusion. there were right to right and left to right collaterals. left ventriculography revealed an ejection fraction of 55 percent with anterior hy

17、pokinesis. dr. picone felt that he was not an ideal candidate for bypass surgery and recommended medical management. mr.zhou was started on a combination of imdur and metoprolol. aspirin was continued. on april 26,20xx,he was still having low chest discomfort. it is difficult to get a complete story

18、 as the patient is chinese speaking only, his daughter interpreted. i spent long periods with the family and describing the procedures and what was done and their implications. they will need to return to see dr.picone in two to three weeks.if he has more chest discomfort, then he may require surgic

19、al intervention. discharge medications medications on discharge are imdur 60 mg p.o.q.d.,metoprolol 25 mg p.o.b.i.d.,lescol 40 mg p.o.q.d.,aspirin 325 mg p.o.q.d.,and norvasc 2.5 mg p.o.q.d. followup follow up with dr.picone in two to three weeks.4出院小結(jié) name: 巴圖吉亞 age: 34 sex: man medical record numb

20、er: 628848 date of admission: 22.dec.20xx. date of discharge: 6.jan.20xx attending physician: zhangchengping present history: 8 years ago,he felt jaundice with no inducing factors，he first consulted local hospital,blood laboratories tests showed hbsag is positive,diagnosised as hepatitis b infection

21、.he was given for treatment,and the liver function becomed normal.1 year ago,he was given interferon for treatment after injection 2 times,the treatment stoped for higher alt than before.since last year,he has taken intermittently pain in the upper abdomen after drunking.from the further treatment,h

22、e admitted to the liver disease department.prior to admission,he has examined liver function and other laboratories.(the result of test:alt u/l,ast u/l,total bilirubin umol/l,total protein g/l,albumin g/l). hospital course: after the patients hostitalization,he was started on heparolysate 100mg i.v.

23、qd,shuganning(舒肝寧注射液) 30ml i.v.qd, compound glycyrrhizin 160mg i.v.qd,wuzhi jiaonang(五酯膠囊) 22.5mg p.o.t.i.d,and jianpi yishen keli(健脾益腎顆粒) 10g p.o.t.i.d.he responded very well to the therapy.up to now,he changes for the better and no obvious uncomfortable. laboratory data: alt u/l,ast u/l,total bili

24、rubin umol/l,total protein g/l,albumin g/l. white cell count ,hemoglobin ,hematocrit ,platelet count ,pt ,afp mg/ml. admitting diagnosis: 1.chronic viral hepatitis with hbv discharge diagnosis: 1.chronic hepatitis b infection. 2.liver cirrhosis(mild). contition on discharge: stable. discharge instru

25、ctions: diet:home diet. activity:as tolerated. discharge medications: continued: 1.wuzhi jiaonang(五酯膠囊) 22.5mg p.o.t.i.d. 2.jianpi yishen keli(健脾益腎顆粒) 10g p.o.t.i.d. new: 1.yinzhihuang keli（茵枝黃顆粒）6g p.o.t.i.d. medical follow up 1.follow up blood routine,prothrombin time(pt),liver function and a-fetoprotein(afp) in 1 month. 2.follow up hbv-marker,hbv-dna,afp and liver ultrasonograph every 6 month. signature:5出院小結(jié)（外科） medical certificate name: - sex: male age:24 inpatient number:- inpatient date: from aug.16,20