英文出院小结

DISCHARGE SUMMERY
NAME: MCKAY WILLIAN SEX: MALE AGE:59 y JOB:lawer
Admission Date: 2014-04-10
Operation Date: 2014-04-16
Discharge Date: 2014-05-01
Admission Dates: 21 days
Diagnosis: 1.thrombus 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, 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 a nd 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 “right superficial femoral vein, popliteal vein,
anterior tibial veins and posterior tibial veins have blood clots”, reviewed color doppler ultrasound prompted” right lower extremity deep venous thrombosis,
convalescence”
2. 2014-04-18 CT Scan of the Lungs prompted: bilateral main pulmonary artery
thrombosis; reviewed CT Scan of the Lungs prompted:” both lower pulmonary arteries (3th branch) thrombosis.”
3. Review INR 1.95
4. color doppler ultrasound of the epididymis prompted” 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/minute.The 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 temperature is t the same as the left limb. The left lower limb is normal.
Treatment : we have use nadroparin calcium and warfarin to anti-freezing, xueshuangtong to promoting blood circulation to remove blood stasis,dextran
and amino acid to expand blood volume.we placed the filter in the inferior caval vein in 2014-4-16, the operation course was successful. In 2014-04-18 CT Scan of the Lungs prompted: bilateral main pulmonary artery thrombosis, so we add a diagnosis pulmonary embolism,we began to give him thrombolytic t herapy. Alteplase 50mg qd
now the INR is 1.95.
discharge diagnosis: 1.thrombus 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.
2.Medicines to improve coagulation function ,keep INR 2~3:warfarin 2.5 pills qn.
∙ 3. Follow-up clinic visit after one week。