匿名使用者
匿名使用者 發問時間: 社會與文化語言 · 10 年前

翻譯英文病層紀錄

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:

(1)Lumbar spine degenerative scoliosis

(2)L4-L5 sponmdylolisthesis and L5-S1 disc space vacuum

phenomenon(+)

(3)Operation method:

L-SPINE LAMINECTOMY

(4)Operation site: L4-S1

(5)Past medical and surgical history: no related

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 degress

O: T:36.9/。c P:57/min R:16/min BP:119/61mmHg

NO fever

Chest:breathing smoothly

Abdomen: soft and no oozing and dry

Motor intact

Hemovac output :770cc/day

(血液)

20100615

Hemoglobin:g/dl 9.3

Hematocrit:% 28.7

A:

Lumbar spine degenerative scoliosis with spinal stenosis syndrome

L4-L5 Degenerative spondylolisthesis

L4-L5 Herniated intervertebral disc, 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

(3)Discectomy,L4-L5and L5-S1

(4)Trans-forminal interbody fusion with Titanium cages,L4-L5

and L5-S1

(5)Local bone graft and osteosets

D:

wound care

pain control

Encourage quadriceps muscle exercise BT with Packed

RBC 2U BT with Packed RBC 2U Add AMG(5cc po qid

keep present treatment

1 個解答

評分
  • 10 年前
    最佳解答

    1.Brief歷史:

    他74歲的女患者因腰背痛

    1年伴有下肢麻木。

    背部的擴展有限實業公司由於疼痛和sorness。

    疼痛的感覺和疼痛明顯重溫時

    坐著躺著(更好的步行)。有脫穎而出,她來到

    我們的鄰門診尋求幫助那裡的X線片顯示:腰椎

    腰椎退變性脊柱側彎,L5sponmdy滑脫和L -中一至中盤

    太空真空現象(+)。由於影響 rehabillitation

    保守治療是有限的,她被送進了

    病房作進一步評估及手術 interverntion。

    2.Pre -運算診斷:

    (1)腰椎退行性脊柱側凸

    (2)腰椎- L5的sponmdylolisthesis及L5 -太空真空中一至中盤

    現象(+)

    (三)操作方法:

    L型脊柱椎板

    (4)操作站點:腰椎,中一

    (5)過去的醫療和手術史:無相關

    7.image

    作為插圖

    8.pre -運算順序完成

    9.schedule檢查

    **指示和Rick很好的解釋,病人和家屬

    理解知情同意完成

    2010/06/15

    學生:傷口疼痛,疼痛評分 8學位的

    Ø:電話:3690 /。ç病人:57/min記:16/min血壓:119/61mmHg

    沒有發燒

    胸圍:呼吸順暢

    腹部:軟,無滲出,乾燥

    汽車完好

    Hemovac輸出:770cc/day

    (血液)

    二千○十萬○六百一十五

    血紅蛋白:克/分升9.3

    紅細胞壓積:28.7%

    答:

    腰椎退變性脊柱側彎合併椎管狹窄症

    腰椎- L5的退行性滑脫

    腰椎,椎間盤脫出症L5的,腰椎間盤

    變性胃潰瘍 S / P值胃大部切除術,貧血

    任擇議定書方法:

    (1)儀器和後外側融合與 RF -Ⅱ,

    腰椎中一

    (2)椎板切除術,腰椎低1 / 3和L5

    (3)椎間盤切除術,腰椎,L5and L5的中一

    (4)跨forminal鈦籠植骨融合,腰椎,L5的

    和L5 -中一

    (五)地方植骨osteosets

    D輯:

    傷口護理

    疼痛控制

    股四頭肌運動,鼓勵電信與盒裝

    英國電信與便攜紅細胞 2U的紅細胞的2U添加的AMG(5cc寶,4次

    保持目前的治療

    參考資料: 一一
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