出院小结英文5篇

出院小结英文出院小结英文 5 5 篇篇 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-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 backThe electrocardiogram(ECG) of the patient showed the ST segment of the leads ,AVF raised mv and was admitted for further evaluation and treatment Cardiovascular Riskfactors: 2-DM, Fat Physical Examination: Blood pressure 120/60mmHg, Pulse 60/ 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: mmol/L( CHOL: /L TG: mmol/L LDL-C: mmol/L HDL: mmol/L CRP: /L (0-8 mg/L) CK-MB: U/L (0-16 U/L) Troponin I: /ml ( ECG: a normal rhythm at rate of 60/minute, ST segment raised mv in leads ,AVF. Transthoracic Echocardiogram(TTE):The size of left atrium is and the other chambers were :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.(/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 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: 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 po 1-0-1 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