出院小结英文.doc

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1、出院小结英文1、英文出院小结DischargeRecordPatientID:0168220Name:XXXXAge:73-y-oSex:Male/FemaleAdmissionDate:XXXXOperationDate:XXXXDischargeDate:XXXXDiagnosis:Acutemyocardialinfraction……RCAcompletelyblocked……LCAhasa50%leisionintheproximalandLADhas30-50%leisionsType2diabetesmellitus(2-DM).Admission:Suddenchest

2、painfor4hoursPatientHistory:73-year-oldmanwithoutsignificantheartproblemspresentedwithsuddenchestpainfor4hours.Andthepainconstantlyradiatedtotheshoulderandback..Theelectrocardiogram(ECG)ofthepatientshowedtheSTsegmentoftheleadsⅡ,Ⅲ,AVFraised0.1-0.2mvandwasadmittedforfurtherevaluationandtreatmentC

3、ardiovascularRiskfactors:2-DM,FatPhysicalExamination:Bloodpressure120/60mmHg,Pulse60/minute.Thelungswereclear.Theheartratewasregular,60beatsperminute.Nomurmurandpericardialrubwasheard.Theabdomenwasunremarkable.Therewasnoperipheraledema.LaboratoryResults:Hb:133g/LGlucose:8.6mmol/L(<6.1)CHOL:4.68

4、mmol/LTG:0.86mmol/LLDL-C:3.07mmol/LHDL:1.11mmol/LCRP:8.60mg/L(0-8mg/L)CK-MB:299.2U/L(0-16U/L)TroponinI:0.24ng/ml(<0.04ng/ml)ECG:anormalrhythmatrateof60/minute,STsegmentraised0.1-0.2mvinleadsⅡ,Ⅲ,AVF.TransthoracicEchocardiogram(TTE):Thesizeofleftatriumis41.2mmandtheotherchamberswerenormal.EF:51%C

5、AG:Themiddleofrightcoronaryartery(RCA)completelyblockedandleftcoronaryartery(LCA)hasa50%leisionintheproximalandleftanteriordescending(LAD)hassome30-50%leisions.Afteradmission,weimplantonestent.(3.5/15mm)intheRCA..Treatment:Afteroperation,trearmentwasstartedfortherecovery.ItwastreatedwithAspirin

6、100mgpoqd,Plavix75mgpoqd,Dilatrend6.25mgbid,Imdur60mgqd,andClexane(low-molecular-weightheparinssodium)5000Uscq12h..After16daysofrecovery,thepatientiswell.Sowethinkthepatientcandischargehospital.Medication:1.MedicinestoimproveheartfunctionandtheirusesAspirin100mgpo1-0-0Plavix75mgpo1-0-0for9month

7、sZocor(statin)40mgpo0-0-1Micardis40mgpo1-0-0Spironolactone20mgpo1-0-0Dilatrend6.25mgpo1-0-12.MedicinestocontrolbloodsugarandtheirusesGlargine(insulin)34Uih1-0-0Glucobay50mgpo1-1-1Avandia8mgpo1-0-0Comments:1.Nosmokinganddrinkingand