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1、 出院小结英文5篇 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、( 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 ,
3、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 abdom
4、en was unremarkable. There was no peripheral edema. Laboratory Results: Hb: 133g/L Glucose: 8.6 mmol/L( 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 ( ECG: a normal rhythm at rate of 60/minute, ST segm
5、ent 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 desce
6、nding(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 he
7、parins 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 S
8、pironolactone 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 n
9、ot do high-intensity exercises 4. 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 1 day.” alcohol triggered. severe, constant pain with nausea & vomiting. more
10、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.
11、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
12、. 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
13、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. Ther
14、e 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 isch
15、emia. 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 5
16、0 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. Pico
17、ne 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
18、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. DI
19、SCHARGE 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
20、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 t
21、reatment,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 l
22、iver 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 patients hostitalization,he was started on heparolysate 100mg I.V.qd,shuganning(舒肝宁注射
23、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
24、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 d
25、iet. 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 m
26、onth. 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 th
27、orough 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
28、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
