出院小结英文
2020-03-03 04:36:41 来源：范文大全收藏下载本文
Discharge Summary
Name：KOUELA-KIKABI ANTOIN Sex：Female Number In Hospital: 297684 Bed Number: F03 Department: Department of gynecology Admiion date：2016-06-30 Age：50-year-old Discharge date：2016-07-11 Duration：11 days
Admitting Diagnosis: uterine fibroid
Discharge Diagnosis: Multiple uterine fibroids
Conditions of Admiion: 1. Chief complain:Abdominal distension more than 10 years, with dysuria, menstruation increase 1 yeMultiple uterine fibroids ar in duration.2. Physical examination: Abdomen: soft, tenderne without rebound pain or rigidity, and bowel sounds with 3 times per minute.Gynecologic examination: Vulva: married has production type. Vagina: unobstructed.The cervical: smooth, no obvious ma. Uterus: the former, increase as six months pregnant, no tenderne, activities. Attachment: double acceories not apparent bag piece, no tenderne 3. Supporting examination:B ultrasound（September-2015Congo）:uterine fibroid
Lab Tests: Blood routine test(2016-7-1): WBC 3.07×10^9/L，NEU% 52.2%，RBC 4.64×10^12/L，HB 144g/L，PLT 308×10^9/L；
Routine urine(2016-7-1):GLU neg(-)mmol/L，BIL neg(-)mmol/L;LEU 25(+)/μl，SPC +/LP；
Blood coagulation function(2016-7-1):PT 10.9s，APTT 27.1s，TT 16.7s，FIB 3.14g/L，DD 0.96mg/L FEU，FDP 5.26mg/L； HCG(2016-7-1)： B-HCG ＜1.20IU/L; Sex hormone test(2016-7-1): PRL 276.00mIU/L,T ＜0.69nmol/L，E2 98.40pmol/L，LH 15.90IU/L，FSH 54.00IU/L, P 0.50nmol/L；
Biochemical test(2016-7-1):TBil 14.2μmol/L，ALT 26U/L，AST 23U/L，Urea 2.38mmol/L，Crea 58.1μmol/L,UA 294μmol/L，Glu 4.64mmol/L； Leucorrhea regular(2016-7-1):PH 4.60，MZSG Ⅱ，DC -，MJ -，WBC 2-3个/HP，SP:a few，XS -， H2O2 ＜2μmol/L; Screening (female) + five of the thyroid gland(2016-7-2):TT3 1.65nmol/L，TT4 88.80nmol/L，TSH 2.35mIU/L，FT3 4.29pmol/L，FT4 13.56pmol/L，AFP_3 2.71ng/ml，CEA 1.40ng/ml，NSE 16.34ng/ml，SCC 0.29ng/ml，CA125 38.23U/ml；
HPV（2016-7-4)：HPV81 （+）
Blood routine test(2016-7-7):WBC 7.69×10^9/L，NEU% 81.1%，RBC 3.85×10^12/L，HB 120g/L，PLT 257×10^9/L，SCRP 92.47mg/L；
Blood coagulation function(2016-7-7):PT 12.0s，APTT 34.1s，TT 14.0s，FIB 4.82g/L，DD 5.47mg/L FEU，FDP 18.97mg/L；
Imaging Examination and Pathological test: X-ray(2016-07-01): no obvious substantial pathologic change was found in both lungs Transabdominal ultrasound(2016-07-02):The uterus increases, multiple uterine fibroids Pelvic MR(2016-07-05): multiple uterine fibroids, partly cystic change.Pathological test（2016-07-08）: The uterus and bilateral tubal excision specimen: (all) of the uterus tumor, multiple leiomyoma with adenoma cells, local hyaline degeneration and mucous degeneration; Endometrial hyperplasia in phase change with endometrial polyps, cervical mucosal chronic inflammation aociated with retention cyst formation and interstitial cells.Fallopian tube, left, right) organization with mesosalpinx cyst (left).
Hospital Course:
The routine diagnostic examinations were taken after admiion.On 2016-07-05 the “Total abdominal hysterectomy + bilateral tubal surgery” was been done and the operation was succeful。Anti-inflammatory and supplemental therapy was taken after the operation.Now, the general condition of the patient is well, so she can be discharged today.
Complication: None.
Physical Examination at Discharge:
General: Awake, alert, no apparent distre Abdomen: Normoactive bowel sounds.Soft.Non-tender, non-distended.CVS: Regular rate and rhythm, no murmurs appreciated.Respiratory: No retractions.Incision: Clean and healing well.
Suggestions after discharge: Instructions:Pay attention to your daily diet , rest and keep the incision clean.Don’t have sexual life 2 month and strenuous exercise.After 1 month to outpatient care;If you have not feeling well,please to outpatient care.Treatment Result: Improving.
Attending：Zu Dexue
Resident：Liu Guju
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