小薇 asked in 社會與文化語言 · 1 decade ago

病程紀錄醫囑誰可以幫我翻(急)

<OP plan>

PLF +posterior instumentation,L2~S1

<OP indiacation>

Spinal stenosis with instability ,failure of conservative treatment

<OP risk>

ASA II

<Brief OP Note>

手術說明:posterolateral fusion,RF L2-L3-L4-L5-S1,laminectomy L2 lower2/3 L3-L4-L5-S upper end,pposterior lumbar interbody fusion L4-5,L5-S1with cages,right iliac bone graft

stenosis atI2-3,L3-4,L4-5,L5-S1 due to facet and ligamentum flavum hypertrophy

P:

<Post-OP Note>

S:Wound pain

O:Vital sign:stable

Wound:no oozing,tenderness and mild swelling

no neurovascular deficit

Hemovac drainage smoothly

A:Degenerative lumbar scoliosis

Lumbar spinal stenosis

Chronic disc degenration L5-S1

P:obs vital sign ,wound condition and hemovac amount

obs motor&sensory condition

Analgesic

Physical therapy

2 Answers

Rating
  • 1 decade ago
    Favorite Answer

    1.http://tw.myblog.yahoo.com/jw!seddrySWAihI92QUS831...

      醫師的部落格,去問問看

    2.這樣會不會太慢?

  • 1 decade ago

    =手術計畫=

    橫棘突間後側方脊椎融合術(postero-lateral spinal fusion, PLF) 脊椎固定器固定 從L2-S1

    =手術指引=

    脊椎狹窄伴隨不穩定, 保守療法無法治療

    =手術風險=

    手術及麻醉風險等級第二級

    =簡短紀錄=

    手術說明:後外側的融合,RF L2-L3-L4-L5-S1,脊板切除術:L2 下2/3部分、L3-L4-L5-S upper end,尾部腰椎內體融合: L4-5,L5放置腰椎椎體護架,用右邊的腸骨移植

    狹窄的部分在 I2-3,L3-4,L4-5,L5-S1, 是由於脊椎面和ligamentum flavum(脊椎上的一種韌帶) 肥大

    P: 計畫

    術後紀錄

    S:Wound pain 主觀因素:傷口疼痛

    O:Vital sign:stable 客觀因素:生命徵像:穩定

    Wound:no oozing,tenderness and mild swelling 傷口: 無滲濕、柔軟且稍許腫

    no neurovascular deficit 沒有神經血管損傷

    Hemovac drainage smoothly 真空引流管順暢

    A:Degenerative lumbar scoliosis 評估:退化性腰椎突出

    Lumbar spinal stenosis 腰椎狹窄

    Chronic disc degenration L5-S1 慢性的脊椎牌退化(L5-S1)

    P:obs vital sign ,wound condition and hemovac amount 計畫: 觀察生命徵象、傷口情形與引流量

    obs motor&sensory condition 觀察動作及知覺情況

    Analgesic 止痛劑

    Physical therapy 物理治療

    Source(s): me,字典
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