有些翻譯找不太到,希望有人可以幫忙謝謝~ 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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