出院小结discharge summary
发布于 2004-03-28 · 浏览 4358 · IP 上海上海
这个帖子发布于 21 年零 42 天前，其中的信息可能已发生改变或有所发展。
最近在心内科收治了一个病人曾在美国住院，看到一份discharge summary，相当于我们的出院小结，文笔简洁清晰，不像我们的病例，程式化的痕迹很重，为了响应prep2usmle的号召，我把它打出来供大家学习。
DICHARGE SUMMARY
DISCHARGE DIAGNOSIS
1. Unstable angina.
2. Multi-vessel artery diease
3. Hyperlipidema
REASON FOR ADMISSION
Mr.Zhou is a 69-year-old Chinese man who is actually a native of Beshing and in the United States visiting his daughter. he presented to the Heart Hospital emergency room with substernal discomfort radiating to the arm. There was mild improvement with nitroglycerin. He had discomfort on and off over a two-day period. He was admitted for further management.
HOSPITAL COURSE
Mr.Zhou ruled out for a myocardial infarction by serial enzymes. An adenosine Cardiolite stress was performed. This showed anterior and inferior ischemia. Caridiac catheterization was then performed by Dr. Picone. Coronary arteriography revealed a subtotal proximal LAD followed by total occlusion mid vessel. The distal LAD filled via collaterals from the circumflex and looked small and diffusely diseased. The circumflex was patent. There was a 50 percent stenosis in the obtuse marginal. The right coronary artery had a 75 percent mid vessel stenosis and a 100 percent distal occlusion. There were right to right and left to right collaterals. Left ventriculography revealed an ejection fraction of 55 percent with anterior hypokinesis. Dr. Picone felt that he was not an ideal candidate for bypass surgery and recommended medical management. Mr.Zhou was started on a combination of Imdur and metoprolol. Aspirin was continued. On April 26,2003,he was still having low chest discomfort. It is difficult to get a complete story as the patient is Chinese speaking only, His daughter interpreted. I spent long periods with the family and describing the procedures and what was done and their implications. They will need to return to see Dr.Picone in two to three weeks.If he has more chest discomfort, then he may require surgical intervention.
DISCHARGE MEDICATIONS
Medications on discharge are Imdur 60 mg p.o.q.d.,metoprolol 25 mg p.o.b.i.d.,Lescol 40 mg p.o.q.d.,aspirin 325 mg p.o.q.d.,and Norvasc 2.5 mg p.o.q.d.
FOLLOWUP
Follow up with Dr.Picone in two to three weeks.
DICHARGE SUMMARY
DISCHARGE DIAGNOSIS
1. Unstable angina.
2. Multi-vessel artery diease
3. Hyperlipidema
REASON FOR ADMISSION
Mr.Zhou is a 69-year-old Chinese man who is actually a native of Beshing and in the United States visiting his daughter. he presented to the Heart Hospital emergency room with substernal discomfort radiating to the arm. There was mild improvement with nitroglycerin. He had discomfort on and off over a two-day period. He was admitted for further management.
HOSPITAL COURSE
Mr.Zhou ruled out for a myocardial infarction by serial enzymes. An adenosine Cardiolite stress was performed. This showed anterior and inferior ischemia. Caridiac catheterization was then performed by Dr. Picone. Coronary arteriography revealed a subtotal proximal LAD followed by total occlusion mid vessel. The distal LAD filled via collaterals from the circumflex and looked small and diffusely diseased. The circumflex was patent. There was a 50 percent stenosis in the obtuse marginal. The right coronary artery had a 75 percent mid vessel stenosis and a 100 percent distal occlusion. There were right to right and left to right collaterals. Left ventriculography revealed an ejection fraction of 55 percent with anterior hypokinesis. Dr. Picone felt that he was not an ideal candidate for bypass surgery and recommended medical management. Mr.Zhou was started on a combination of Imdur and metoprolol. Aspirin was continued. On April 26,2003,he was still having low chest discomfort. It is difficult to get a complete story as the patient is Chinese speaking only, His daughter interpreted. I spent long periods with the family and describing the procedures and what was done and their implications. They will need to return to see Dr.Picone in two to three weeks.If he has more chest discomfort, then he may require surgical intervention.
DISCHARGE MEDICATIONS
Medications on discharge are Imdur 60 mg p.o.q.d.,metoprolol 25 mg p.o.b.i.d.,Lescol 40 mg p.o.q.d.,aspirin 325 mg p.o.q.d.,and Norvasc 2.5 mg p.o.q.d.
FOLLOWUP
Follow up with Dr.Picone in two to three weeks.
最后编辑于 2022-10-09 · 浏览 4358
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