出院小结英文.docx
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出院小结英文.docx
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出院小结英文
出院小结英文
1、英文出院小结
DischargeRecord
PatientID:
0168220
Name:
XXXX
Age:
73-y-oSex:
Male/Female
AdmissionDate:
XXXX
OperationDate:
XXXX
DischargeDate:
XXXX
Diagnosis:
Acutemyocardialinfraction
……RCAcompletelyblocked
……LCAhasa50%leisionintheproximalandLADhas30-50%leisions
Type2diabetesmellitus(2-DM).
Admission:
Suddenchestpainfor4hours
PatientHistory:
73-year-oldmanwithoutsignificantheartproblemspresentedwithsuddenchestpainfor4hours.Andthepainconstantlyradiatedtotheshoulderandback..Theelectrocardiogram(ECG)ofthepatientshowedtheSTsegmentoftheleadsⅡ,Ⅲ,AVFraised0.1-0.2mvandwasadmittedforfurtherevaluationandtreatment
CardiovascularRiskfactors:
2-DM,Fat
PhysicalExamination:
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/L
CRP:
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)completelyblockedandleftcoronaryartery(LCA)hasa50%leisionintheproximalandleftanteriordescending(LAD)hassome30-50%leisions.Afteradmission,weimplantonestent.(3.5/15mm)intheRCA..
Treatment:
Afteroperation,trearmentwasstartedfortherecovery.ItwastreatedwithAspirin100mgpoqd,Plavix75mgpoqd,Dilatrend6.25mgbid,Imdur60mgqd,andClexane(low-molecular-weightheparinssodium)5000Uscq12h..After16daysofrecovery,thepatientiswell.Sowethinkthepatientcandischargehospital.
Medication:
1.Medicinestoimproveheartfunctionandtheiruses
Aspirin100mgpo1-0-0
Plavix75mgpo1-0-0for9months
Zocor(statin)40mgpo0-0-1
Micardis40mgpo1-0-0
Spironolactone20mgpo1-0-0
Dilatrend6.25mgpo1-0-1
2.Medicinestocontrolbloodsugarandtheiruses
Glargine(insulin)34Uih1-0-0
Glucobay50mgpo1-1-1
Avandia8mgpo1-0-0
Comments:
1.Nosmokinganddrinkingandkeepdiet
2.Strictlycontrollbloodsugar
3.Beattentiontokeeprestanddonotdohigh-intensityexercises
4.Eatmedicinesontimeandfollow-upvisitafteronemonth.
Dotor:
XXXXXX
2、英文出院小结
姓名ZhaoXX性别male年龄51
入院诊断Acutepancreatitis
简要病史、体格检查和入院辅助检查Complaints:
'leftupperabdominalpainfor1day.'alcoholtriggered.severe,constantpainwithnausea&vomiting.moreintensewhensupine,butrelievedbystayingwiththetrunkflexedandkneesdrawnup.noradiation.noabdominaldistention.nogallstonehistory.Physicalexamination:
low-gradefever.normaltoelevatedBP.distressed,anxious.jaundice(-).moderateabdominaltenderness,withnomusclerigidity.Laboratorydata:
serumamylase↑,serumlipase↑,urineamylase↑,whitebloodcells↑,plasmaglucose↑.CTplaintscan:
noindicativesign.gastroduodenalendoscopy:
inflammatorychanges,noulcerobserved.etc.
治疗经过:
fasting.intravenousfluids.nutritionalsupport.nasogastricsuction.prophylacticantibiotic.inhibitingpancreaticsecretion.othersincludingconsultations.
出院转归:
resolutionofabdominalpain
出院诊断:
Acutepancreatitis
出院医嘱:
avoidanceofalcohol.fluiddietgraduallytoregulardiet.symptomsobservation.hospitalizationwhennecessary.
3、英文出院小结
DICHARGESUMMARY
DISCHARGEDIAGNOSIS
1.Unstableangina.
2.Multi-vesselarterydiease
3.Hyperlipidema
REASONFORADMISSION
Mr.Zhouisa69-year-oldChinesemanwhoisactuallyanativeofBeshingandintheUnitedStatesvisitinghisdaughter.hepresentedtotheHeartHospitalemergencyroomwithsubsternaldiscomfortradiatingtothearm.Therewasmildimprovementwithnitroglycerin.Hehaddiscomfortonandoffoveratwo-dayperiod.Hewasadmittedforfurthermanagement.
HOSPITALCOURSE
Mr.Zhouruledoutforamyocardialinfarctionbyserialenzymes.AnadenosineCardiolitestresswasperformed.Thisshowedanteriorandinferiorischemia.CaridiaccatheterizationwasthenperformedbyDr.Picone.CoronaryarteriographyrevealedasubtotalproximalLADfollowedbytotalocclusionmidvessel.ThedistalLADfilledviacollateralsfromthecircumflexandlookedsmallanddiffuselydiseased.Thecircumflexwaspatent.Therewasa50percentstenosisintheobtusemarginal.Therightcoronaryarteryhada75percentmidvesselstenosisanda100percentdistalocclusion.Therewererighttorightandlefttorightcollaterals.Leftventriculographyrevealedanejectionfractionof55percentwithanteriorhypokinesis.Dr.Piconefeltthathewasnotanidealcandidateforbypasssurgeryandrecommendedmedicalmanagement.Mr.ZhouwasstartedonacombinationofImdurandmetoprolol.Aspirinwascontinued.OnApril26,20XX,hewasstillhavinglowchestdiscomfort.ItisdifficulttogetacompletestoryasthepatientisChinesespeakingonly,Hisdaughterinterpreted.Ispentlongperiodswiththefamilyanddescribingtheproceduresandwhatwasdoneandtheirimplications.TheywillneedtoreturntoseeDr.Piconeintwotothreeweeks.Ifhehasmorechestdiscomfort,thenhemayrequiresurgicalintervention.
DISCHARGEMEDICATIONS
MedicationsondischargeareImdur60mgp.o.q.d.,metoprolol25mgp.o.b.i.d.,Lescol40mgp.o.q.d.,aspirin325mgp.o.q.d.,andNorvasc2.5mgp.o.q.d.
FOLLOWUP
FollowupwithDr.Piconeintwotothreeweeks.
4、出院小结
name:
巴图吉亚
age:
34
sex:
man
medicalrecordnumber:
628848
dateofadmission:
22.Dec.20XX.
dateofdischarge:
6.Jan.20XX
attendingphysician:
zhangchengping
presenthistory:
8yearsago,hefeltjaundicewithnoinducingfactors,hefirstconsultedlocalhospital,bloodlaboratoriestestsshowedHBsAgispositive,diagnosisedashepatitisBinfection.hewasgivenfortreatment,andtheliverfunctionbecomednormal.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(舒肝宁注射液)30mlI.V.qd,compoundglycyrrhizin160mgI.V.qd,wuzhijiaonang(五酯胶囊)22.5mgP.O.t.i.d,andjianpiyishenkeli(健脾益肾颗粒)10gP.O.t.i.d.herespondedverywelltothetherapy.uptonow,hechangesforthebetterandnoobviousuncomfortable.
Laboratorydata:
ALTU/L,ASTU/L,totalbilirubinumol/L,totalproteing/L,albuming/L.
Whitecellcount,hemoglobin,hematocrit,plateletcount,PT,AFPmg/ml.
admittingdiagnosis:
1.chronicviralhepatitiswithHBV
dischargediagnosis:
1.chronichepatitisBinfection.
2.livercirrhosis(mild).
Contitionondischarge:
Stable.
dischargeinstructions:
diet:
homediet.
Activity:
astolerated.
DischargeMedications:
Continued:
1.wuzhijiaonang(五酯胶囊)22.5mgP.O.t.i.d.
2.jianpiyishenkeli(健脾益肾颗粒)10gP.O.t.i.d.
New:
1.yinzhihuangkeli(茵枝黄颗粒)6gP.O.t.i.d.
Medicalfollowup
1.followupbloodroutine,prothrombintime(PT),liverfunctionanda-fetoprotein(AFP)in1month.
2.followupHBV-marker,HBV-DNA,AFPandliverultrasonographevery6month..
signature:
5、出院小结(外科)
MedicalCertificate
Name:
-----sex:
maleage:
24inpatientnumber:
-------
Inpatientdate:
fromAug.16,20XXtoSep.20,20XX
Diagnosis:
portalhypertension,livercirrhosis
Courseoftreatment:
First,wehadathoroughexaminationforthispatient,
includingphysicalexamination,bloodexaminationandimageexamination
(Allthedatamentionedabovehadbeencopiedbythepatient).Thenwehad
thediagnosis:
portalhypertension,livercirrhosis.And,inAug.26,20XX
weunderwenttheoperation:
splenectomywithesophagustransectionandanastomosis,andesophagogastricdevascularization.Afteroperation
thepatienthadgotabasicrecoveryandwasdischargedonSep.20,20XX.
Instructions:
1.Itissuggestedthatheshouldrestforonemonthathomebeforeresuminghiswork.
2.Seedoctorandhavesomenecessaryexaminationregularly.
3.Seedoctoranytimewhenfeelinguncomfortable.
Doctorincharge:
Professor----------
20XX-10-9
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