※ 引述《suger82 ()》之铭言： : 有些翻译找不太到,希望有人可以帮忙谢谢~ : 1.Brief history: 简短病史 : his 74-year-old female patient suffered from low back pain : for 1 year accompanied by lower leg numbness. 74岁女性下背痛合并下肢麻木一年 : Extension of back was limited limitted due to pain and sorness. 因为酸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). 当坐下或躺下的时候这些酸痛会缓解(比走路时好) 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. 所以他来我们骨科的门诊求诊，安排的X光显示腰椎退化性侧弯合并第四、五腰椎滑脱， 及第五腰椎第一腰椎椎间椎间盘空间有真空现象。因为保守治疗及复健的效果有限， 所以他被收入院做进一步的评估及手术的介入。 : 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荐椎椎间盘内有真空现象 : (3)Operation method:手术方法 : 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 risk well explained,patient and family : understood inform consent completed 手术适应症及风险已完整解释，病人及家属都完全了解手术同意书之内容 : 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 胃溃疡接受次全胃切除术後，贫血 : OP Method: : (1)Posterior instrumentation and posterolateral fusion with RF-II, : L4-S1 以RF系统施行後侧内固定及後外侧融合术，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 以钛合金鸟笼施行经椎孔椎间融合术，L4/5 : (5)Local bone graft and osteosets : D: 骨移植及人工骨移植 : 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 鼓励股四头肌训练 请将FB及MSN附回邮寄回...谢谢 -- 这是我的部落格...有图有真相... 纯粹医疗学术讨论... http://tw.myblog.yahoo.com/ort-chen --

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