Medical Record: Chest Pain

 

Source  原文

 

Target  译文
姓名:XXXX       性别: XXXX      年龄:XX

入院日期: XXXXX

出院日期: XXXXX

门(急)诊诊断:胸痛待查

入院诊断:胸痛待查、冠状动脉粥样硬化心脏病、高血压病

出院诊断:肺栓塞合并腹部感染、冠状动脉粥样硬化心脏病、高血压病、脂肪肝、高胆红素血症?

 

 

入院时主要症状及体征

患者因“胸痛3天”入院。查体:神清,查体合作,全身未见瘀点瘀斑,对答切题,未见颈静脉充盈,两肺未及明显干湿啰音,心律尚齐,76次/分,全腹部平软,无明显压痛以及反跳痛,四肢肌力正常,双下肢不肿。

 

 

 

住院期间主要化验结果

2014-6-13 电解质:钾 4.06 mmol/L,钠141 mmol/L, 氯105 mmol/L,二氧化碳结合率20.2 mmol/L ↓;心脏酶:肌酸激酶52 U/L,肌酸酶同工酶0.6 ng/ml,肌钙蛋白I0.01 ng/ml,肌红蛋白21.4 ng/ml。类风湿因子< 9.94 IU/ml,抗“O”试验117 IU/mL。凝血全套:凝血酶原时间11.60 s,部分凝血酶原时间35.30 s,凝血酶时间14.40 s,纤维蛋白原1.62 g/L ↑,D-二聚体测定0.29mg/L。血沉77.00 mm/h ↑。降钙素原< 0.1 ng/ml。

2014-6-16   血沉44.00 mm/h ↑。血常规:白细胞7.10 x 109/L,中性粒细胞比率63.96%,C反应蛋白15.22 mg/L ↑。肿瘤指标:甲胎蛋白5.13 ng/ml,癌胚抗原1.65 ng/ml,糖类抗原CA-125 4.00 U/mL,糖类抗原 CA 19-9 3.09 U/mL

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住院期间特殊检查结果及重要会诊

6-13 胸部CT:右肺中叶炎症,右侧胸膜增厚;腹部彩超:脂肪肝。心电图:HR84次/分,窦性心律,频发室性早搏。6-19  下肢血管彩超:右侧下肢股总动脉及大隐静脉开口处低回声。6-22  肺动脉造影:双侧肺动脉分支多发肺动脉栓塞,右肺中叶炎症。

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Name: XXXXXX     Gender: XXXX  Age: XX

Admittance Date:  XXXXX

Discharge Date:  XXXXX

Outpatient (emergency) Diagnosis: Chest pain pending investigation

Diagnosis at admittance: Chest pain pending investigation, coronary atherosclerosis, hypertension

Diagnosis at discharge: Pulmonary embolism combined with lung infection, coronary atherosclerosis, hypertension, hepatic steatosis, hyperbilirubinemia?

 

Main Symptoms and Signs at Admittance

Patient admitted because of “chest pain for 3 days.” Examination: Alert, able to cooperate with exam, no petechia or ecchymosis observed anywhere on body; answered questions to the point; no jugular vein engorgement observed; no obvious dry or moist rales in either lung; heart rhythm normal, 76 beats/min; entire abdomen soft, no obvious tenderness or rebound tenderness; muscle strength in limbs normal; neither leg swollen.

 

Results of Main Tests During Hospitalization

June 13, 2014   Electrolytes: potassium 4.06 mmol/L, sodium 141 mmol/L, chloride 105 mmol/L, CO2 combining rate 20.2 mmol/L ↓; Cardiac enzymes:  creatine kinase 52 U/L, creatine kinase isoenzymes 0.6 ng/ml, troponin I 0.01 ng/ml, myoglobin 21.4 ng/ml. Rheumatoid factor < 9.94 IU/ml, anti-streptolysin O test 117 IU/mL. Complete coagulation panel: prothrombin time 11.60 s, partial thromboplastin time 35.30 s, thrombin time 14.40 s, fibrinogen 1.62 g/L ↑, D-dimer test 0.29mg/L. Blood sedimentation 77.00 mm/h ↑. Procalcitonin < 0.1 ng/ml.

2014-6-16   Blood sedimentation 44.00 mm/h ↑. Complete blood count: white blood cell count 7.10 x 109/L, granulocyte percentage 63.96%, C-reactive protein 15.22 mg/L ↑. Tumor markers: alpha-feto protein 5.13 ng/ml, carcinoembryonic antigen 1.65 ng/ml, carbohydrate antigen CA-125 4.00 U/mL, carbohydrate antigen CA 19-9 3.09 U/mL

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Results of Specialized Tests and Key Consultations During Hospitalization

6-13 Chest CT: inflammation in right middle lobe of lung, thickening of right pleura. Abdominal ultrasound: hepatic steatosis. Electrocardiograph: HR84 beats/min, sinus rhythm with frequent premature ventricular contractions.  6-19  Lower limb vascular ultrasound: right lower limb common femoral artery and saphenous opening hypoechoic.  6-22  Pulmonary arteriography: multiple bilateral pulmonary branch emboli, inflammation in right middle lobe.

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