出院小结英文新选

1、出院小结英文1、英文出院小结Discharge RecordPatient ID:0168220Name: XXXXAge:73-y-o Sex: Male/FemaleAdmission Date: XXXXOperation Date: XXXXDischarge Date: XXXXDiagnosis:Acute myocardial infraction-50% leisionsRCA completely b lockedLCA has a 50% leision in the proximal and LAD has 30Type 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 n ,田,AVF

3、raised 0.1-0.2 mv and was admitted for furtherevaluation 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 u

4、nremarkable. 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, ST se

5、gment raised 0.1-0.2 mv in leads n, m ,avf.Transthoracic Echocardiogram(TTE):The size of left atrium is 41.2mm and theother chambers were normal.EF:51%CAG: The middle of right coronary artery(RCA) completely blocked and leftcoronary artery (LCA) has a 50% leision in the proximal and left anterior de

6、scending(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 wastreated with Aspirin 100mgpo qd , Plavix 75mgpo qd, Dilatrend 6.25mg bid, Imdur 60mgqd, and Clexane(low-molecular-weight hepa

7、rins 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 1-0-0Spironola

8、ctone 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-inten

9、sity exercises4. Eat medicines on time and follow-up visit after one month.Dotor: XXXXXX2、英文出院小结姓名Zhao XX 性别 male年龄51入院诊断 Acute pancreatitis简要病史、体格检查和入院辅助检查Complaints:left upper abdominal pain for 1day. alcohol triggered. severe, constant pain with nausea & vomiting. more intense when supine, but re

10、lieved 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. Laboratory data: serum amyla

11、se T ,serum lipase T ,urine amylase T ,white blood cells T , plasma glucose T . CTplaint scan: no indicative sign. gastro duodenal endoscopy: inflammatory changes, no ulcer observed. etc.治疗经过：fasting. intravenous fluids. nutritional support. nasogastric suction. prophylactic antibiotic. inhibiting p

12、ancreatic secretion. others including consultations.出院转归：resolution of abdominal pain出院诊断： Acute pancreatitis出院医嘱：avoidance of alcohol. fluid diet gradually to regular diet. symptoms observation. hospitalization when necessary.3、英文出院小结DICHARGE SUMMARYDISCHARGE DIAGNOSIS1. Unstable angina.2. Multi-ve

13、ssel 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 thearm. There was mildimprovement w

14、ith 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 catheteriza

15、tion 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 stenosis in the

16、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 he was not an

17、 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 speaking only, Hisd

18、aughter 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 MEDICATIONSMedication

19、s 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、出院小结name: 巴图吉亚age: 34 sex: manmedical record number: 628848 date of admission: 22.Dec.20XX.date of dis

20、charge: 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.he was given for treatment,and the liver function be

21、comed 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 abdomenafter drunking.from the further treatment,he admitted to the liver disease department.prior to ad

22、mission,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 100mgI.V.qd,shuganning（舒肝宁注射液 ）30ml I.V.qd, compound glycyrrhizin

23、 160mgI.V.qd,wuzhi jiaonang（五酯胶囊）22.5mg P.O.t.i.d,and jianpi yishen keli（健脾益肾颗粒）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 ,

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

25、inued:1.wuzhi jiaonang(五酯胶囊)22.5mg P.O.t.i.d.2.jianpi yishen keli(健脾益肾颗粒）10g P.O.t.i.d.New:1.yinzhihuang keli（茵枝黄颗粒）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、出院小结(外科)Medical CertificateName:sex: male age:24 inpatient number:Inpatient date: