英文出院记录

DischargeSummaryName：YanJingyunSex：FemaleAge：54-year-oldAdmissiondate：2008-05-22Dischargedate：2008-5-25Duration：3daysConditionsatadmission：ChiefComplaint:Paroxysmalprecordialpainformorethan4years,exacerbates4monthsinduration.Historyofpresentillness:About4yearsago,atthetimeofstayinginCanadian,thepatientwenttohospitalbecauseofparoxysmalprecordialpain,thecoronaryangiographyundergonethereshowedhigh-gradestenosisinproximalleftanteriordescending(LAD)coronaryartery.Thusastentwasplacedthere.Inthepast4months,shehadprecordialpainonexertion,thechestpainwanedandwaxed.Pasthistory:15-yearhistoryofarterialhypertension,denyanyhistoryofpriordiabetesmellitus.Physicalexamination：T:36.2℃P:68bpmR:16bpmBp:130/80mmHg，alert，obesity,nocyanosis，nojugularveindistention，thesoundofbreathisclearwithoutanydryormoistrales，heartsizeisnormalonpercussion，HR68bpm，regularrhythm，nomurmuronauscultation,abdominaldistentionwithouttenderness，nohepatomegalyorsplenomegaly,shiftingdullnessnegative，noedemaexistsinthelegs。AdmissionDiagnosis：CoronaryheartdiseaseUnstableanginapectorisPost-PCIOldmyocardialinfarction(anteriorwall)?PrimaryhypertensionHospitalcourse：Theroutinediagnosticexaminationsweretakenafteradimssion.Serumlipid：CHOL4.6mmol/L,TG5.96mmol/L,HDL-C0.8mmol/l,LDL-C1.96mmol/l。Fastingglucose：5.6mmol/L，Postprandialbloodsugar：12.1mmol/L，thechestX-rayexamination、echocardiography、nephricfunctionexamination、liverfunctionexaminationandbloodroutineexaminationshownoobviousabnormality，thecoronaryangiographyshows:norestenosisofthestentinproximalLAD，50％narrowingofproximalrightcoronaryartery(RCA)，totalocclusionattheendof2ndsegmentofRCA.AnattempttopassaguidewireacrosstheCTOofRCAfailed.Conditionsatdischarge：Thepatientfeelsnodiscomfort，Physicalexamination：T:36.4℃P:76bpmR:17bpmBp:110/70mmHg，alert，obesity,nocyanosis，nojugularveindistention，thesoundofbreathisclearwithoutanydryormoistrales，heartsizeisnormalonpercussion，HR76bpm，regularrhythm，nomurmuronauscultation,abdominaldistentionwithouttenderness，nohepatomegalyorsplenomegaly,shiftingdullnessnegative，noedemaexistsinthelegs。DischargeDiagnosis：CoronaryheartdiseaseUnstableanginapectorisPost-PCIPrimaryhypertensionDiabetestypeIIMedications：Metoprolol25mgbid，IsosorbideMononitrate60mgqd，Felodipine5mgqd，Aspirin100mgqd，Telmisartan40mgqd，Atorvastatin20mgqd，Clopidogrel75mgqd。Attending：AnLiminResident：ZhangXinghua