出院小结英文
1英文出院小结
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 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 segment of the leads Ⅱ,Ⅲ,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 was heard. The abdomen was unremarkable. 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/L
CRP: 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 segment raised 0.1-0.2 mv in leads Ⅱ,Ⅲ,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 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-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
Micardis 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 keep rest and do not do high-intensity exercises
4. Eat medicines on time and follow-up visit after one month.
Dotor: XXXXXX
2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 1 day." alcohol triggered. severe, constant pain with nausea & 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 no 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.
治疗经过：fasting. intravenous fluids. nutritional support. nasogastric suction. prophylactic antibiotic. inhibiting pancreatic 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 SUMMARY
DISCHARGE DIAGNOSIS
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 radiating 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 anterior 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 patent. 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 hypokinesis. 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 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 surgical 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出院小结
name: 巴图吉亚
age: 34
sex: man
medical record number: 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.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,he 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 patient`s hostitalization,he was started on heparolysate 100mg I.V.qd,shuganning(舒肝宁注射液) 30ml I.V.qd, compound glycyrrhizin 160mg I.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 ,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 instructions:
diet:home diet.
Activity:as tolerated.
Discharge Medications:
Continued:
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 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出院小结（外科）
Medical Certificate
Name: ----- sex: male age:24 inpatient number:-------
Inpatient date: from Aug.16,20XX to Sep.20 ,20XX
Diagnosis:portal hypertension, liver cirrhosis
Course of treatment: First, we had a thorough examination for this patient,
including physical examination, blood examination and image examination
(All the data mentioned above had been copied by the patient).Then we had
the diagnosis: portal hypertension, liver cirrhosis. And, in Aug.26,20XX
we underwent the operation:splenectomy with esophagus transection and anastomosis, and esophagogastric devascularization. After operation
the patient had got a basic recovery and was discharged on Sep.20 ,20XX.
Instructions:
1.It is suggested that he should rest for one month at home before resuming his work.
2.See doctor and have some necessary examination regularly.
3.See doctor anytime when feeling uncomfortable.
Doctor in charge: Professor ----------
20XX-10-9