北京安定医院门诊病例记录中译英翻译加拿大公证处律师认证

Beijing Anding Hospital

Outpatient Medical Record

Visitors: Patient, Parents

Is the visitor information verified: Yes

Does the patient meet the high-risk maternal standards (during pregnancy and within 42 days postpartum): No

Content: Patient's condition: Stable; Mental state: Improved; Sleep condition: Insomnia; Eating condition: Good; Bowel movements: Regular; Sometimes difficult to fall asleep, and sometimes early to wake up. Studying abroad, starting freshman year in September. In January 2021, due to insomnia and low mood, he sought medical attention and took sertraline and quetiapine. After taking the medication, his memory was poorer and his mood improved, but he had gastrointestinal problems and drowsiness. After 10 months, he stopped using the medication. After discontinuing medication, his mood worsened, feeling bored living, with suicidal thoughts, sometimes tired, weak, and too much in bed, and not satisfied with his appearance, always looking in the mirror. In January 2023, he sought medical attention in the United States and was given 10mg of escitalopram in the morning. His mood improved to some extent, but he was still anxious about his appearance. He often took melatonin for sleep but stopped during holidays.

Medication situation: Regular medication; escitalopram 10mg in the morning

Discomfort reaction: No obvious discomfort;

Physical condition: good;

Physical examination (please describe any abnormalities): No obvious abnormalities;

Beijing Anding Hospital

Outpatient Medical Record

Mental examination: quiet.

Treatment

Medication:

Acecitalopram oxalate         10mg ①*7 tablets/box      20mg   orally once a day           8 boxes

Reminder and suggestion: Acecitalopram 20 mg in the morning, but 15 mg in the morning for the first 2 days. A

Whether to transfer to community health service institutions/township health centers, name of medical institution to be accepted

Physician's signature: XXX

20234124 翻译公证件 病历 样本.pdf

20234124