出院小结英文

1 / 17 出院小结英文 Discharge report gynecology Bed number： 15 Name： LIN YUAN Birth Gender： female 50 Y 11214696 Age： Number in hospital： Lead doctor 2 / 17 resident Date gynecology Bed number： 15 Name： LIN YUAN Birth Gender： female Age： 50 Y Number in hospital： 11214696 Pathological Report： Secretory endometrium with the 3 / 17 formation of polyps. 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: 4 / 17 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 ,AVF raised mv and was admitted for further evaluation and treatment Cardiovascular Riskfactors: 2-DM, Fat 5 / 17 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 6 / 17 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 7 / 17 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 rest and do not do high-intensity exercises 8 / 17 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 9 / 17 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 10 / 17 DISCHARGE DIAGNOSIS DISCHARGE SUMMERY NAME: MCKAY WILLIAN SEX: MALE AGE:59 y JOB:lawer Admission Date: 2016-04-10 Operation Date: 2016-04-16 Discharge Date: 2016-05-01 Admission Dates: 21 days Diagnosis: of right lower extremity veins Admission: right lower limb edema and pain for 1 month Patient History: 59y-old man presented with his right lower limb edema and pain after 15 hours air trip one month ago. without cough, expectoration, hemoptysis, 11 / 17 ague, fever or dyspnea. So he came to our emergency ward for further treatment, color doppler ultrasound prompted “right superficial femoral vein, popliteal vein, Anterior tibial veins and posterior tibial veins have blood clots”. He was admitted for further evaluation and treatment. Physical Examination: edema of right lower limb,with skin swelling ,and the skin temperature is higher than the left limb .No rash, no pruritus, no Venous distention. The right trigonum femorale , popliteal space and gastrocnemius pain while percussed. absence of right-side dorsalis pedis artery pulse. The left lower limb is normal. Laboratory Results: 1. color doppler ultrasound prompted “rightanterior tibial veins and posterior tibial veins have blood clots”, reviewed color doppler ultrasound 12 / 17 prompted” right lower extremity deep venous thrombosis, convalescence” 2. 2016-04-18 thrombosis; reviewed CT Scan of the Lungs prompted:” both lower pulmonary arteries (3th branch) thrombosis.” 3. Review INR 4. color doppler ultrasound ” epididymitis(left)” discharge situation: without cough, expectoration, hemoptysis, ague, fever or dyspnea. General status normal. Spirit, sleep, appetite normal. Stool, urine normal. Physical Examination: Pulse 72/ lungs were clear. The heart rate was regular, 72beats per minute. No murmur and pericardial rub was heard. The abdomen was unremarkable. A little edema of right lower limb,without skin swelling ,and the skin 13 / 17 temperature is t the same as the left limb. The left lower limb is normal. Treatment : we have use xueshuangtong to promoting blood circulation to remove blood stasis,dextran 2016-4-16, the operation course was successful. In 2016-04-18 CT Scan of the thrombosis, so we add a diagnosis therapy. Alteplase 50mg qd now the INR is discharge diagnosis: of right lower extremity veins 2. pulmonary embolism 3. epididymitis(left) ? Comments: 1. No smoking and drinking and keep diet, don t walk too much, don t sit for a long time. 14 / 17 to improve ,keep INR 23: warfarin pills qn. ? 3. Follow-up clinic visit after one week 出院小结翻译 Admission diagnosis: infection and intracranial infection 2. post-renal transplantation Admission situation and treatment: 58-year-old man, related donor renal transplantation in April XX, the function of transplanted kidney was normal. Received surgical therapy one after another in . because of sinus a year ago. The pathological section of first surgery() showed that it is likely to be fungal infection(most likely to be aspergillus),but didn t show any evidence on fungal infection thereafter. Pain in the left side of the forehead remission less obvious after operation, and the vision of left eye 15 / 17 declined December 2016, at wuhan union hospital department of ophthalmology, suspected as optic neuritis and received High-dose steroid pulse therapy and Decreasing therapy for about one month. Had a fever(37-38)with headache aggravated in march,2016, the CT showed the possibility of fungal infection of the left sphenoid sinus, and received antifungal therapy(Mycamine for one week, then voriconazole dropped for one week), instead of oral voriconazole after body temperature was normal and discharged. Reexamination of CT one month later showed the range of infection of the left sphenoid sinus get patient had a rise in temperature(about )and headache aggravated again, after oral voriconazole for two months, the appetite and body weight declined patient came to our hospital by July 21,2016,the outpatient CT showed the range of infection of sinus get larger again,.At July 23,the MRI and MRI enhancement scan showed infection of left sphenoid sinus and cavernous sinus, abscess formation of frontal lobe. First of all, we gave Mycamine(150mg,qd) after admission, the following day read as 16 / 17 voriconazole(,bid),posaconazole(10ml,bid)and Linezolid Injection(,qd) for anti-infection therapy, and stopped all