出院小结英文

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 back..The electrocardiogram(ECG) of the patient showed the ST segment of the leads Ⅱ,Ⅲ,AVF raised 0.1-0.2 mv and was admitted for further evaluation and treatment

Cardiovascular Riskfactors: 2-DM, Fat

Physical Examination: Blood pressure 120/60mmHg, Pulse 60/minute.The 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: 8.6 mmol/L(<6.1)

CHOL: 4.68mmol/L TG: 0.86 mmol/L LDL-C: 3.07 mmol/L HDL: 1.11 mmol/L

CRP: 8.60mg/L (0-8 mg/L)

CK-MB: 299.2 U/L (0-16 U/L) Troponin I: 0.24ng/ml (< 0.04 ng/ml)

ECG: a normal rhythm at rate of 60/minute, ST segment raised 0.1-0.2 mv in leads Ⅱ,Ⅲ,AVF.

Transthoracic Echocardiogram(TTE):The size of left atrium is 41.2mm and the other chambers were normal.EF: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.(3.5/15 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 6.25mg 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:

1.Medicines 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 6.25mg po 1-0-1

2.Medicines 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

4. Eat medicines on time and follow-up visit after one month.

Dotor: XXXXXX