※ 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 請將FB及MSN附回郵寄回...謝謝 -- 這是我的部落格...有圖有真相... 純粹醫療學術討論... http://tw.myblog.yahoo.com/ort-chen --

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