出院小结英文文档格式.docx

出院小结英文文档格式.docx

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XXXX

Age:

73-y-oSex:

Male/Female

AdmissionDate:

OperationDate:

DischargeDate:

Diagnosis:

Acutemyocardialinfraction

……RCAcompletelyblocked

……LCAhasa50%leisionintheproximalandLADhas30-50%leisions

Type2diabetesmellitus（2-DM）.

Admission:

Suddenchestpainfor4hours

PatientHistory:

73-year-oldmanwithoutsignificantheartproblemspresentedwithsuddenchestpainfor4hours.Andthepainconstantlyradiatedtotheshoulderandback..Theelectrocardiogram（ECG）ofthepatientshowedtheSTsegmentoftheleadsⅡ,Ⅲ,AVFraisedmvandwasadmittedforfurtherevaluationandtreatment

CardiovascularRiskfactors:

2-DM,Fat

PhysicalExamination:

Bloodpressure120/60mmHg,Pulse60/lungswereclear.Theheartratewasregular,60beatsperminute.Nomurmurandpericardialrubwasheard.Theabdomenwasunremarkable.Therewasnoperipheraledema.

LaboratoryResults:

Hb:

133g/LGlucose:

mmol/L（<

CHOL:

LTG:

mmol/LLDL-C:

mmol/LHDL:

mmol/L

CRP:

L（0-8mg/L）

CK-MB:

U/L（0-16U/L）TroponinI:

ml（<

ng/ml）

ECG:

anormalrhythmatrateof60/minute,STsegmentraisedmvinleadsⅡ,Ⅲ,AVF.

TransthoracicEchocardiogram（TTE）:

Thesizeofleftatriumisandtheotherchamberswere:

51%

CAG:

Themiddleofrightcoronaryartery（RCA）completelyblockedandleftcoronaryartery（LCA）hasa50%leisionintheproximalandleftanteriordescending（LAD）hassome30-50%leisions.Afteradmission,weimplantonestent.15mm）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.Piconefeltthathewasnotan