精神分裂症 英文病历报告

June 5, 2010
Our local doctor in SH led patient to Shanghai Mental Health Center at 2 PM this afternoon then visited psychiatrian there. Following is updated information for the patient. The insured came to Shanghai in Dec of 2009 to study Chinese. In January 2010 the Chinese course finished then he started to live in an apartment alone. He admitted since April of 2010 visual/audio hallucination started. On May 9 he visited psychiatrian in UFH of Shanghai then Olanzapine was administered in out-patient department, until he was admitted there on May 29 for operation of Tibia/fibula fracture. Upon discharge of UFH SH, anti-schizophrenia agent Abilify 5 mg Bid and Clonazapam 2mg QN were ever prescript. Upon enquiry by the psychiatrian in SH Mental Health Center this afternoon, the insured showed state of alert, easy contact. He still complained instructive audio-hallucination and persecutive feeling (delusion). He felt somtimes his thought was fully perspected by others. However, no tendency of violent assaulting or obvious depression were noted. He had no recognization of his condition being sicked.
Diagnosis: schizophrenia
Treatment/advice: 1. Olanzapine 5 mg Bid.
2. He should follow up in out-patient department 1
week later to regulate(add?) dose of Olanzapine.
3. His current condition permits travel now, but
under medical escort.
4. He should be monitored by relation or caregiver
for regular use of medication after back to UK. In
this case, there is no need to be admitted into
hospital for therapy. If there is none to look after
him for medication taking, admission of hospital is
advised after he is back to UK.
After the visit of psychiatrian finished this afternoon, the insured was sent to Changning District Central Hospital for cardiologist visit.
There was no discomfort complaint of chest depress or shortness of breath. His vital signs as BP, T, RR, HR and oxygen saturation were in normal range. Heart and lungs (-).
ECG of this afternoon: normal.
Labs done this afternoon
Blood routine: WBC 10800(normal < 10000), with LYM 41%.
CK, CK-MB, Tryponin etc were in normal range.
Coagulation function tests were basically in normal range.
Blood platelet cell: 380000(100000-300000)
D-dimmer result was normal.
The cardiologist thought his heart condition was stable now, no impression of cardiac ischemia. Then he was prescript Cefuroxime tabs and L-Glutamine, Sodium Gualenate Granules. The cardiologist thought his heart condition would not disturb his travel.
The current medications he is taking now:
1. Oxycodone/Paracetamol tabs (painkiller)
2. Cefuroxime tabs
3. L-Glutamine, Sodium Gualenate Granules
4. Aripiprozole tabs
Hope above information will be helpful to you.。