英文出院记录

英文出院记录 Discharge Summary Name:Yan Jingyun Sex:Female Age:54-year-old 2008-05-22 Discharge date:2008-5-25 Duration:3 days Admission date: Conditions at admission: Chief Complaint:Paroxysmal precordial pain for more than 4 years, exacerbates 4 months in duration. History of present illness:About 4 years ago ,at the time of staying in Canadian,the patient went to hospital because of paroxysmal precordial pain,the coronary angiography undergone there showed high-grade stenosis in proximal left anterior descending(LAD)coronary artery.Thus a stent was placed there.In the past 4 months,she had precordial pain on exertion,the chest pain waned and waxed. Past history:15-year history of arterial hypertension,deny any history of prior diabetes mellitus. Physical examination:T:36.2? P:68bpm R:16bpm Bp: 130/80mmHg～alert～ obesity,no cyanosis～no jugular vein distention～the sound of breath is clear without any dry or moist rales～heart size is normal on percussion～ HR68bpm～regular rhythm～no murmur on auscultation,abdominal distention without tenderness～no hepatomegaly or splenomegaly,shifting dullness negative～no edema exists in the legs。 Admission Diagnosis: Coronary heart disease Unstable angina pectoris Post-PCI Old myocardial infarction(anterior wall)? Primary hypertension Hospital course: The routine diagnostic examinations were taken after adimssion. Serum lipid:CHOL4.6mmol/L,TG 5.96mmol/L,HDL-C 0.8mmol/l,LDL-C 1.96mmol/l。 Fasting glucose:5.6mmol/L～Postprandial blood sugar:12.1mmol/L～the chest X-ray examination、echocardiography、nephric function examination、liver function examination and blood routine examination show no obvious abnormality～the coronary angiography shows: no restenosis of the stent in proximal LAD～50, narrowing of proximal right coronary artery(RCA)～ total occlusion at the end of 2nd segment of RCA. An attempt to pass a guidewire across the CTO of RCA failed. Conditions at discharge: The patient feels no discomfort～Physical examination:T:36.4? P:76bpm R:17bpm Bp: 110/70mmHg～alert～obesity,no cyanosis～no jugular vein distention～the sound of breath is clear without any dry or moist rales～heart size is normal on percussion～HR76bpm～regular rhythm～no murmur on auscultation,abdominal distention without tenderness～no hepatomegaly or splenomegaly,shifting dullness negative～no edema exists in the legs。 Discharge Diagnosis: Coronary heart disease Unstable angina pectoris Post-PCI Primary hypertension Diabetes typeII Medications: Metoprolol 25mg bid～ Isosorbide Mononitrate 60mg qd～ Felodipine 5mg qd～ Aspirin 100mg qd～ Telmisartan 40mg qd～ Atorvastatin 20mg qd～ Clopidogrel 75 mg qd。 Attending:An Limin Resident:Zhang Xinghua