发布时间:2019-10-18 13:43:54



患者的出院记录单翻译成无论是英文,日语,我们都做了无数的案例,除了具备相应的医学翻译资质,我们还做了国外医院尤其是美国医院的翻译宣誓词:official translation的方式和资质,得到了包括麻省总医院,约翰霍普金斯,休斯顿安德森癌症中心,凯瑟琳医院,洛杉矶医学中心的支持。


Anshan Center Hospital

Discharge records

Name: panda                   Sex: male              Age: 22 years old                 Dept .: Respiratory Ward - Tiedong Branch 

Bed number: 42              Medical record number: 312544

Admission time: November 19, 2018 Discharge time: December 3, 2018 Admission days: 15

Surgery time:      Pathology number:          X Slice number:                     

Admission diagnosis: Community-acquired pneumonia

Discharge diagnosis: Community-acquired pneumonia

Admission conditions: The patient was admitted in the hospital because of chief complaints of fever accompanied by cough and sputum for four days. The patient's disease began 4 days ago without obvious inducement to appear fever, no measurement of temperature, accompanied by cough, yellow myxoid sputum. Then he took chinese herbal compound for clearing heat and detoxifcation but did no get better. At four o'clock this morning, the patient, because of aggravation of illness and about 38 degrees Celsius of body temperature, came to our hospital for emergency treatment. Blood tests were normal. Chest radiograph showed that the texture of both lungs was enhanced, and lamellar fuzzy shadows could be seen in the lower and middle fields of the left lung. It was considered as left pneumonia and the patient was given Levofloxacin and Reduning injection. However, he still had fever and was admitted in our hospital due to left pneumonia for further treatment. During the disease, he had no hemoptysis, chills, breathing difficulties and abnormal defecation but had occasional chest pain, cough aggravation and poor appetite and sleep. Chest radiograph showed that the texture of both lungs was enhanced, and lamellar fuzzy shadows could be seen in the lower and middle fields of the left lung.

The main test results: At 10:58:40, October 8, 2018, biochemical Group 1: Creatine kinase: 366.6 366.6U / L; At 07:47:52, October 14, 2018, Rummage blood: C-reactive protein: 16.67 16.67mg / L, platelet: 471.00 471.0010 ^ 9 / L

Main course of treatment: The Patient, after admitting to hospital, perfected examination, clarified diagnosis and accepted symptomatic treatment of anti-infection, phlegm reduction, microwave, etc..

Discharge conditions: temperature:36.5 degrees Celsius, Pulse: 80 beats / min, Breathing: 16 beats / min, Blood pressure: 130 / 80mhg. The patient had a clear consciousness, normal profile, sternum without percussion pain and normal breast symmetry. He had normal respiratory motion, intercostal space, vocal fremitus and had percussion voiceless sound and regular breathing. The double lungs breathing sounded thick and there was no pleural friction sound. There was no protuberance in the precordial part. The apical beat and cardiac turbidity were normal and the heart rate was regular. No murmur was heard in the auscultation area of each valve, and there was no frictional sound in the pericardium. He had a flat abdomen, no varicose abdominal wall, soft abdomen, no tenderness and rebound pain and no mass in the abdomen. Liver was untouched. Morphy's sign was negative. The kidney had no percussion pain and no shifting dullness. Bowel sounds were normal with a speed of 4 times/min. No swelling was found in both lower limbs.

Treatment results: better

Discharge Instructions: 1. Review blood routine examination and lung CT after discharge for one month and follow up outpatient respiratory department.

2. Health Education: pay attention to preventing cold and keeping warm

Discharge whereabouts: 1

1. Home (discharge according to doctor’s order);2 To transfer to another hospital accordingly and the name of medical institution to be accepted:

3. To transfer to community health services / township hospitals and the name of medical institution to be accepted:

4. Leave hospital without medical advice   5. Death   9. Others

Discharge medicines: Amine-pinan capsule; 1 capsule per time; take orally three times a day.

Treatment of a nearby hospital with conditions for diagnosis and treatment

Attending physician:     Date: 14:08, December 3, 2018    Resident doctor: Zhang Hang   Date: 14:08, December 3, 2018





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