出院小結(jié)英文5篇

出院小結(jié)英文5篇英文出院小結(jié)DischargeRecordPatientID:0168220Name:xxAge:73-y-oSex:Male/FemaleAdmissionDate:xxOperationDate:xxDischargeDate:xxDiagnosis:Acutemyocardialinfraction……RCApletelyblocked……LCAhasa50%leisionintheproximalandLADhas30-50%leisionsType2diabetesmellitus(2-DM).Admission:Suddenchestpainfor4hoursPatientHistory:73-year-oldmanwithoutsignificantheartproblemspresentedwithsuddenchestpainfor4hours.Andthepainconstantlyradiatedtotheshoulderandback..Theelectrocardiogram(ECG)ofthe

patientshowedtheSTsegmentoftheleadsⅡ,Ⅲ,AVFraised0.1-0.2mvandwasadmittedforfurtherevaluationandtreatmentCardiovascularRiskfactors:2-DM,FatPhysicalExamination:Bloodpressure120/60mmHg,Pulse60/minute.Thelungswereclear.Theheartratewasregular,60beatsperminute.Nomurmurandpericardialrubwasheard.Theabdomenwasunremarkable.Therewasnoperipheraledema.LaboratoryResults:Hb:133g/LGlucose:8.6mmol/L(<6.1)CHOL:4.68mmol/LTG:0.86mmol/LLDL-C:3.07mmol/LHDL:1.11mmol/LCRP:8.60mg/L(0-8mg/L)CK-MB:299.2U/L(0-16U/L)TroponinI:0.24ng/ml(<0.04ng/ml)ECG:anormalrhythmatrateof60/minute,STsegmentraised0.1-0.2mvinleadsⅡ,Ⅲ,AVF.TransthoracicEchocardiogram(TTE):Thesizeofleftatriumis41.2mmandtheotherchamberswerenormal.EF:51%CAG:Themiddleofrightcoronaryartery(RCA)pletelyblockedandleftcoronaryartery(LCA)hasa50%leisionintheproximalandleftanterior

descending(LAD)hassome30-50%leisions.Afteradmission,weimplantonestent.(3.5/15mm)intheRCA..Treatment:Afteroperation,trearmentwasstartedfortherecovery.ItwastreatedwithAspirin100mgpoqd,Plavix75mgpoqd,Dilatrend6.25mgbid,Imdur60mgqd,andClexane(low-molecular-weightheparxxsodium)5000Uscq12h..After16daysofrecovery,thepatientiswell.Sowethinkthepatientcandischargehospital.Medication:1.MedicinestoimproveheartfunctionandtheirusesAspirin100mgpo1-0-0Plavix75mgpo1-0-0for9monthsZocor(statin)40mgpo0-0-1Micardis40mgpo1-0-0Spironolactone20mgpo1-0-0Dilatrend6.25mgpo1-0-12.MedicinestocontrolbloodsugarandtheirusesGlargine(xxulin)34Uih1-0-0Glucobay50mgpo1-1-1

Avandia8mgpo1-0-0ments:1.Nosmokinganddrinkingandkeepdiet2.Strictlycontrollbloodsugar3.Beattentiontokeeprestanddonotdohigh-intensityexercises4.Eatmedicinesontimeandfollow-upvisitafteronemonth.Dotor:xx英文出院小結(jié)姓名Zhaoxx性別male年齡51入院診斷Acutepancreatitis簡要病史、體格檢查和入院輔助檢查plaints:”leftupperabdominalpainfor1day.”alcoholtriggered.severe,constantpainwithnausea&vomiting.moreintensewhensupine,butrelievedbystayingwiththetrunkflexedandkneesdrawnup.noradiation.noabdominaldistention.nogallstonehistory.Physicalexamination:low-gradefever.normaltoelevatedBP.distressed,anxious.jaundice(-).moderateabdominaltenderness,withnomusclerigidity.Laboratorydata:serum

amylase↑,serumlipase↑,urineamylase↑,whitebloodcells↑,plasmaglucose↑.CTplaintscan:noindicativesign.gastroduodenalendoscopy:inflammatorychanges,noulcerobserved.etc.治療經(jīng)過：phylacticantibiotic.inhibitingpancreaticsecretion.othersincludingconsultations.出院轉(zhuǎn)歸：resolutionofabdominalpain出院診斷：Acutepancreatitis出院醫(yī)囑：avoidanceofalcohol.fluiddietgraduallytoregulardiet.symptomsobservation.hospitalizationwhennecessary.英文出院小結(jié)DICHARGESUMMARYDISCHARGEDIAGNOSIS1.Unstableangina.2.Multi-vesselarterydiease

3.HyperlipidemaREASONFORADMISSIONMr.Zhouisa69-year-oldChinesemanwhoisactuallyanativeofBeshingandintheUnitedStatesvisitinghisdaughter.hepresentedtotheHeartHospitalemergencyroomwithsubsternaldisfortradiatingtothearm.Therewasmildimprovementwithnitroglycerin.Hehaddisfortonandoffoveratwo-dayperiod.Hewasadmittedforfurthermanagement.HOSPITALCOURSEMr.Zhouruledoutforamyocardialinfarctionbyserialenzymes.AnadenosineCardiolitestresswasperformed.Thisshowedanteriorandinferiorischemia.CaridiaccatheterizationwasthenperformedbyDr.Picone.CoronaryarteriographyrevealedasubtotalproximalLADfollowedbytotalocclusionmidvessel.ThedistalLADfilledviacollateralsfromthecircumflexandlookedsmallanddiffuselydiseased.Thecircumflexwaspatent.Therewasa50percentstenosisintheobtusemarginal.Therightcoronaryarteryhada75percentmidvesselstenosisanda100percentdistalocclusion.Therewererighttorightandlefttorightcollaterals.Leftventriculographyrevealedanejectionfractionof55percentwithanteriorhypokinesis.Dr.Piconefeltthathewasnotanidealcandidateforbypasssurgeryandremendedmedicalmanagement.

Mr.ZhouwasstartedonabinationofImdurandmetoprolol.Aspirinwascontinued.OnApril26,xx,hewasstillhavinglowchestdisfort.ItisdifficulttogetapletestoryasthepatientisChinesespeakingonly,Hisdaughterinterpreted.Ispentlongperiodswiththefamilyanddescribingtheproceduresandwhatwasdoneandtheirimplications.TheywillneedtoreturntoseeDr.Piconeintwotothreeweeks.Ifhehasmorechestdisfort,thenhemayrequiresurgicalintervention.DISCHARGEMEDICATIONSMedicationsondischargeareImdur60mgp.o.q.d.,metoprolol25mgp.o.b.i.d.,Lescol40mgp.o.q.d.,aspirin325mgp.o.q.d.,andNorvasc2.5mgp.o.q.d.FOLLOWUPFollowupwithDr.Piconeintwotothreeweeks.出院小結(jié)name:巴圖吉亞age:34sex:manmedicalrecordnumber:628848

dateofadmission:22.Dec.xx.dateofdischarge:6.Jan.xxattendingphysician:zhangchengpingpresenthistory:8yearsago,hefeltjaundicewithnoinducingfactors，hefirstconsultedlocalhospital,bloodlaboratoriestestsshowedHBsAgispositive,diagnosisedashepatitisBinfection.hewasgivenfortreatment,andtheliverfunctionbeednormal.1yearago,hewasgiveninterferonfortreatmentafterinjection2times,thetreatmentstopedforhigherALTthanbefore.sincelastyear,hehastakenintermittentlypainintheupperabdomenafterdrunking.fromthefurthertreatment,headmittedtotheliverdiseasedepartment.priortoadmission,hehasexaminedliverfunctionandotherlaboratories.(theresultoftest:ALTU/L,ASTU/L,totalbilirubinumol/L,totalproteing/L,albuming/L).

hospitalcourse:afterthepatient`shostitalization,hewasstartedonheparolysate100mgI.V.qd,shuganning(舒肝寧注射液)30mlI.V.qd,poundglycyrrhizin160mgI.V.qd,wuzhijiaonang(五酯膠囊)22.5mgP.O.t.i.d,andjianpiyishenkeli(健脾益腎顆粒)10gP.O.t.i.d.herespondedverywelltothetherapy.uptonow,hechangesforthebetterandnoobviousunfortable.Laboratorydata:ALTU/L,ASTU/L,totalbilirubinumol/L,totalproteing/L,albuming/L.Whitecellcount,hemoglobin,hematocrit,plateletcount,PT,AFPmg/ml.admittingdiagnosis:1.chronicviralhepatitiswithHBVdischargediagnosis:

1.chronichepatitisBinfection.2.livercirrhosis(mild).Contitionondischarge:Stable.dischargexxtructions:diet:homediet.Activity:astolerated.DischargeMedications:Continued:1.wuzhijiaonang(五酯膠囊)2

2.5mgP.O.t.i.d.2.jianpiyishenkeli(健脾益腎顆粒)10gP.O.t.i.d.New:1.yinzhihuangkeli（茵枝黃顆粒）6gP.O.t.i.d.Medicalfollowup1.followupbloodroutine,prothrombintime(PT),liverfunctionanda-fetoprotein(AFP)in1month.2.followupHBV-marker,HBV-DNA,AFPandliverultrasonographevery6month..signature:出院小結(jié)（外科）MedicalCertificate

Name:-----sex:maleage:24inpatientnumber:-----