出院小結(jié)英文

1、出院小結(jié)英文1、英文出院小結(jié)Discharge RecordPatient ID:0168220Name: XXXXAge:73-y-o Sex: Male/FemaleAdmission Date: XXXXOperation Date: XXXXDischarge Date: XXXXDiagnosis:Acute myocardial infractionRCA completely blockedLCA has a 50% leision in the proximal and LAD has 30-50% leisionsType 2 diabetes mellitus( 2-DM)

2、.Admission: Sudden chest pain for 4 hoursPatient 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 segment of the leads ,AVF raise

3、d 0.1-0.2 mv and was admitted for further evaluation and treatmentCardiovascular Riskfactors: 2-DM, FatPhysical 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 was heard. The abdomen was unre

4、markable. There was no peripheral edema.Laboratory Results:Hb: 133g/L Glucose: 8.6 mmol/L(<6.1)CHOL: 4.68mmol/L TG: 0.86 mmol/L LDL-C: 3.07 mmol/L HDL: 1.11 mmol/LCRP: 8.60mg/L (0-8 mg/L) CK-MB: 299.2 U/L (0-16 U/L) Troponin I: 0.24ng/ml (< 0.04 ng/ml)ECG: a normal rhythm at rate of 60/minute,

5、 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 left anterior

6、 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-molecular-weig

7、ht 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 usesAspirin 100mg po 1-0-0Plavix 75mg po 1-0-0 for 9 monthsZocor(statin) 40mg po 0-0-1Micardis 40mg po 1-0-0Spi

8、ronolactone 20mg po 1-0-0Dilatrend 6.25mg po 1-0-12.Medicines to control blood sugar and their usesGlargine(insulin) 34U ih 1-0-0Glucobay 50mg po 1-1-1Avandia 8mg po 1-0-0Comments:1. No smoking and drinking and keep diet2. Strictly controll blood sugar3. Be attention to keep rest and do not do high-

9、intensity exercises4. 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 nausea & vomiting. more in

10、tense 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 no muscle rigidity. La

11、boratory 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. prophylactic antibiotic. i

12、nhibiting 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 SUMMARYDISCHARGE DIAGNOSIS1. Unstable angina.2

13、. Multi-vessel artery diease3. HyperlipidemaREASON FOR ADMISSIONMr.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 radiating to the arm. There was mild i

14、mprovement with nitroglycerin. He had discomfort on and off over a two-day period. He was admitted for further management.HOSPITAL COURSEMr.Zhou ruled out for a myocardial infarction by serial enzymes. An adenosine Cardiolite stress was performed. This showed anterior and inferior ischemia. Caridiac

15、 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 patent. There was a 50 percent sten

16、osis 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 hypokinesis. Dr. Picone felt that h

17、e 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 as the patient is Chinese speaki

18、ng 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 surgical intervention.DISCHARGE MEDICAT

19、IONSMedications 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.FOLLOWUPFollow up with Dr.Picone in two to three weeks.4、出院小結(jié)name: 巴圖吉亞age: 34sex: manmedical record number: 628848date of admission: 22.Dec.20XX

20、.attending physician: zhangchengpingpresent 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.he was given for treatment,and the liver function becomed normal.1 year a

21、go,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,he admitted to the liver disease department.prior to admission,he has exami

22、ned 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.qd,shuganning(舒肝寧注射液) 30ml I.V.qd, compound glycyrrhizin 160mg I.V.qd,wuzhi

23、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 bilirubin umol/L,total protein g/L,albumin g/L.White cell count ,hemoglobin ,hemat

24、ocrit ,platelet count ,PT ,AFP mg/ml.admitting diagnosis:1.chronic viral hepatitis with HBVdischarge diagnosis:1.chronic hepatitis B infection.2.liver cirrhosis(mild).Contition on discharge:Stable.discharge instructions:diet:home diet.Activity:as tolerated.Discharge Medications:Continued:1.wuzhi jia

25、onang(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 up1.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 CertificateName: - sex: male age:24 inpatient num