骨科病程翻譯 - 手術

※ 引述《suger82 ()》之銘言：
: 有些翻譯找不太到,希望有人可以幫忙謝謝~
: 1.Brief history:
簡短病史
: his 74-year-old female patient suffered from low back pain
: for 1 year accompanied by lower leg numbness.
74歲女性下背痛合併下肢麻木一年
: Extension of back was limited limitted due to pain and sorness.
因為痠痛所以背部的伸展受限
: The sensation of pain and soreness was much relived when
: sitting and lying down(better the walking).
當坐下或躺下的時候這些痠痛會緩解(比走路時好)

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.
所以他來我們骨科的門診求診，安排的X光顯示腰椎退化性側彎合併第四、五腰椎滑脫，
及第五腰椎第一腰椎椎間椎間盤空間有真空現象。因為保守治療及復健的效果有限，
所以他被收入院做進一步的評估及手術的介入。
: 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薦椎椎間盤內有真空現象
: (3)Operation method:手術方法
: 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 risk well explained,patient and family
: understood inform consent completed
手術適應症及風險已完整解釋，病人及家屬都完全了解手術同意書之內容
: 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
胃潰瘍接受次全胃切除術後，貧血
: OP Method:
: (1)Posterior instrumentation and posterolateral fusion with RF-II,
: L4-S1
以RF系統施行後側內固定及後外側融合術，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
以鈦合金鳥籠施行經椎孔椎間融合術，L4/5
: (5)Local bone graft and osteosets
: D:
骨移植及人工骨移植
: 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
鼓勵股四頭肌訓練


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