骨科病程翻譯 - 手術

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1.Brief history:
his 74-year-old female patient suffered from low back pain
for 1 year accompanied by lower leg numbness.
Extension of back was limited limitted due to pain and sorness.
The sensation of pain and soreness was much relived when
sitting and lying down(better the walking).There fore, she came
to our ortho OPD for help where x-ray showed: Lumbar spine
degenerative scoliosis L4-L5sponmdy lolisthesis and L-S1 disc
space vacuum phenomenon(+).Due to the of effect of rehabillitation
and conservative treatment were limited,she was admitted to out
ward for further evaluation and surgical interverntion.


2.Pre-op diagnosis:手術前診斷
(1)Lumbar spine degenerative scoliosis腰椎退化性脊椎側彎
(2)L4-L5 sponmdylolisthesis and L5-S1 disc space vacuum phenomenon(+)
第4-5節腰椎脊椎滑脫和第5腰椎與S1薦椎椎間盤內有僵直性脊椎炎
(3)Operation method:方法
L-SPINE LAMINECTOMY 腰椎椎板切除
(4)Operation site: L4-S1
(5)Past medical and surgical history: no related過去內外科病史:無相關



7.image
as illustration
8.pre-op-order completed
9.schedule checked
**indication and rick well explained,patient and family
understood inform consent completed
2010/06/15
S:wound pain and pain score 8 degres
s主觀:傷口疼痛和疼痛指數8 degress
O: T:36.9/。c P:57/min R:16/min BP:119/61mmHg
客觀:體溫36.9/。c 脈搏:57/min 呼吸:16/min 血壓:119/61mmHg
NO fever無發燒
Chest:breathing smoothly 胸部:呼吸順暢
Abdomen: soft and no oozing and dry
腹部：軟，無滲出液，乾燥
Motor intact
Hemovac output :770cc/day
(血液)
20100615
Hemoglobin:g/dl 9.3血紅素:g/dl 9.3
Hematocrit:% 28.7血球比容:% 28.7

A:
Lumbar spine degenerative scoliosis with spinal stenosis syndrome
腰椎退化性脊椎側彎伴隨脊椎狹窄症候群
L4-L5 Degenerative spondylolisthesis
第4-5節腰椎診斷為脊椎滑脫症
L4-L5 Herniated intervertebral disc, Lumbar spine disc
第4-5節腰椎椎間盤突出,Lumbar spine disc
degeneration Gastric ulcer s/p subtotal gastrectomy,Anemia
OP Method:
(1)Posterior instrumentation and posterolateral fusion with RF-II,
L4-S1
(2)Laminectomy,L4 lower 1/3 and L5 椎間盤切除術,
(3)Discectomy,L4-L5and L5-S1
椎間盤切除術,第4-5腰椎和第5腰椎與S1薦椎
(4)Trans-forminal interbody fusion with Titanium cages,L4-L5
and L5-S1
(5)Local bone graft and osteosets
D:
wound care 傷口護理
pain control 疼痛控制
Encourage quadriceps muscle exercise BT with Packed
RBC 2U BT with Packed RBC 2U Add AMG(5cc po qid
keep present treatment


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