ECG:
anormalrhythmatrateof60/minute,STsegmentraisedmvinleadsⅡ,Ⅲ,AVF.
TransthoracicEchocardiogram（TTE）:
Thesizeofleftatriumisandtheotherchamberswere:
51%
CAG:
Themiddleofrightcoronaryartery（RCA）completelyblockedandleftcoronaryartery（LCA）hasa50%leisionintheproximalandleftanteriordescending（LAD）hassome30-50%leisions.Afteradmission,weimplantonemm）intheRCA..
Treatment:
Afteroperation,trearmentwasstartedfortherecovery.ItwastreatedwithAspirin100mgpoqd,Plavix75mgpoqd,Dilatrendbid,Imdur60mgqd,andClexane（low-molecular-weightheparinssodium）5000Uscq12h..After16daysofrecovery,thepatientiswell.Sowethinkthepatientcandischargehospital.
Medication:
toimproveheartfunctionandtheiruses
Aspirin100mgpo1-0-0
Plavix75mgpo1-0-0for9months
Zocor（statin）40mgpo0-0-1
Micardis40mgpo1-0-0
Spironolactone20mgpo1-0-0
Dilatrendpo1-0-1
tocontrolbloodsugarandtheiruses
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
isa69-year-oldChinesemanwhoisactuallyanativeofBeshingandintheUnitedStatesvisitinghisdaughter.hepresentedtotheHeartHospitalemergencyroomwithsubsternaldiscomfortradiatingtothearm.Therewasmildimprovementwithnitroglycerin.Hehaddiscomfortonandoffoveratwo-dayperiod.Hewasadmittedforfurthermanagement.
HOSPITALCOURSE
ruledoutforamyocardialinfarctionbyserialenzymes.AnadenosineCardiolitestresswasperformed.Thisshowedanteriorandinferiorischemia.CaridiaccatheterizationwasthenperformedbyDr.Picone.CoronaryarteriographyrevealedasubtotalproximalLADfollowedbytotalocclusionmidvessel.ThedistalLADfilledviacollateralsfromthecircumflexandlookedsmallanddiffuselydiseased.Thecircumflexwaspatent.Therewasa50percentstenosisintheobtusemarginal.Therightcoronaryarteryhada75percentmidvesselstenosisanda100percentdistalocclusion.Therewererighttorightandlefttorightcollaterals.Leftventriculographyrevealedanejectionfractionof55percentwithanteriorhypokinesis.Dr.Piconefeltthathewasnotanidealcandidateforbypasssurgeryandrecommendedmedicalmanagement.wasstartedonacombinationofImdurandmetoprolol.Aspirinwascontinued.OnApril26,20XX,hewasstillhavinglowchestdiscomfort.ItisdifficulttogetacompletestoryasthepatientisChinesespeakingonly,Hisdaughterinterpreted.Ispentlongperiodswiththefamilyanddescribingtheproceduresandwhatwasdoneandtheirimplications.Theywillneedtoreturntoseeintwotothreehehasmorechestdiscomfort,thenhemayrequiresurgicalintervention.
DISCHARGEMEDICATIONS
MedicationsondischargeareImdur60mg25mg40mg325mgNorvascmgupwithintwotothreeweeks.
4、出院小结
name:
巴图吉亚
age:
34
sex:
man
medicalrecordnumber:
628848
dateofadmission:
ofdischarge:
physician:
zhangchengping
presenthistory:
8yearsago,hefeltjaundicewithnoinducingfactors，hefirstconsultedlocalhospital,bloodlaboratoriestestsshowedHBsAgispositive,diagnosisedashepatitisBwasgivenfortreatment,andtheliverfunctionbecomedyearago,hewasgiveninterferonfortreatmentafterinjection2times,thetreatmentstopedforhigherALTthanlastyear,hehastakenintermittentlypainintheupperabdomenafterthefurthertreatment,headmittedtotheliverdiseasetoadmission,hehasexaminedliverfunctionandotherlaboratories.（theresultoftest:
ALTU/L,ASTU/L,totalbilirubinumol/L,totalproteing/L,albuming/L）.
hospitalcourse:
afterthepatient`shostitalization,hewasstartedonheparolysate100mg舒肝宁注射液）30mlcompoundglycyrrhizin160mgjiaonang（五酯胶囊）jianpiyishenkeli（健脾益肾颗粒）10grespondedverywelltothetonow,hechangesforthebetterandnoobviousuncomfortable.
Laboratorydata:
ALTU/L,ASTU/L,totalbilirubinumol/L,totalproteing/L,albuming/L.
Whitecellcount,hemoglobin,hematocrit,plateletcount,PT,AFPmg/ml.
admittingdiagnosis:
viralhepatitiswithHBV
dischargediagnosis:
hepatitisBinfection.
cirrhosis（mild）.
Contitionondischarge:
Stable.
dischargeinstructions:
diet:
homediet.
Activity:
astolerated.
DischargeMedications:
Continued:
jiaonang（五酯胶囊）yishenkeli（健脾益肾颗粒）10gkeli（茵枝黄颗粒）6gfollowup
upbloodroutine,prothrombintime（PT）,liverfunctionanda-fetoprotein（AFP）in1month.
upHBV-marker,HBV-DNA,AFPandliverultrasonographevery6month..
signature:
5、出院小结（外科）
MedicalCertificate
Name:
-----sex:
maleage:
24inpatientnumber:
-------
Inpatientdate:
from,20XXto,20XX
Diagnosis:
portalhypertension,livercirrhosis
Courseoftreatment:
First,wehadathoroughexaminationforthispatient,
includingphysicalexamination,bloodexaminationandimageexamination
（Allthedatamentionedabovehadbeencopiedbythepatient）.Thenwehad
thediagnosis:
portalhypertension,livercirrhosis.And,in,20XX
weunderwenttheoperation:
splenectomywithesophagustransectionandanastomosis,andesophagogastricdevascularization.Afteroperation
thepatienthadgotabasicrecoveryandwasdischargedon,20XX.
Instructions:
issuggestedthatheshouldrestforonemonthathomebeforeresuminghiswork.
doctorandhavesomenecessaryexaminationregularly.
doctoranytimewhenfeelinguncomfortable.
Doctorincharge:
Professor----------
20XX-10-9
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