有些翻译找不太到,希望有人可以帮忙谢谢~ 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:手术前诊断 (1)Lumbar spine degenerative scoliosis腰椎退化性脊椎侧弯 (2)L4-L5 sponmdylolisthesis and L5-S1 disc space vacuum phenomenon(+) 第4-5节腰椎脊椎滑脱和第5腰椎与S1荐椎椎间盘内有僵直性脊椎炎 (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过去内外科病史:无相关 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主观:伤口疼痛和疼痛指数8 degress O: T:36.9/。c P:57/min R:16/min BP:119/61mmHg 客观:体温36.9/。c 脉搏:57/min 呼吸:16/min 血压:119/61mmHg NO fever无发烧 Chest:breathing smoothly 胸部:呼吸顺畅 Abdomen: soft and no oozing and dry 腹部：软，无渗出液，乾燥 Motor intact Hemovac output :770cc/day (血液) 20100615 Hemoglobin:g/dl 9.3血红素:g/dl 9.3 Hematocrit:% 28.7血球比容:% 28.7 A: Lumbar spine degenerative scoliosis with spinal stenosis syndrome 腰椎退化性脊椎侧弯伴随脊椎狭窄症候群 L4-L5 Degenerative spondylolisthesis 第4-5节腰椎诊断为脊椎滑脱症 L4-L5 Herniated intervertebral disc, Lumbar spine disc 第4-5节腰椎椎间盘突出,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 椎间盘切除术, (3)Discectomy,L4-L5and L5-S1 椎间盘切除术,第4-5腰椎和第5腰椎与S1荐椎 (4)Trans-forminal interbody fusion with Titanium cages,L4-L5 and L5-S1 (5)Local bone graft and osteosets D: wound care 伤口护理 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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