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Sean asked in 健康其他:保健 · 10 years ago

請幫我看看病歷摘要中是否有有提到手術過程紀錄

住院治療及經過

The 14y/o boy with past historyof 1. duednum stenosis s/p op three times.

2. A loop syndrome s/p reversed operation with gstrrhaphy , small intestine resection with anastomosis and pyloroplasty on 93-7-8 was admitted to our ward due to chest pain and vomiting several times.

Lab data revealed leukocytosis with neutrophil predominant. He didn’t have URI symptoms and Diarrhea.

The chest pain was retrosternal dull pain without radiation and the ECG revealed no

obvious abomity. The vomitus was non-bilius food contant. Poor appetite and poor activity were decreased.

The impression was GERD. After admission , pediatric CV was consulted and

suggested doing GERD evaluation.

24hrs esophageal PH moniter was arranged on 93-7-28and

revealed negative finding.

Esophgogram was arrangedand revealed no obvious esophageal stricture or abnormity. Under stable condition , he was MBD on 93-7-31 and suggested to receive OPD follow up.

由於兵役複檢需要開刀紀錄,但是我家離醫院很遠

所以找到以前醫院開出的出院病歷摘要

看看內容有沒有詳細提到手術經過 做哪一類的手術

麻煩請專業人士幫我看一下內容是否有提到"手術內容"

不用完全翻譯 謝謝

如果有任何疑問請發問 我會補充說明

Update:

那請問 給外科醫生看 他就知道手術的方法跟經過嗎?

需不需要另準備手術紀錄?

2 Answers

Rating
  • 提姆
    Lv 7
    10 years ago
    Favorite Answer

    1. 這位14歲的男孩有十二指腸阻塞(狹窄)的過往史,接受過三次手術治療。(沒有提到術式)

    2. 因數度胸痛及嘔吐的近端腸管症候群,住到本院。並於93年7月8日,接受還原手術,胃壁修補術、小腸切除與接合及幽門成形術。

    後面的報告提到實驗室數據及住院病程。

    2010-08-01 23:34:40 補充:

    那請問 給外科醫生看 他就知道手術的方法跟經過嗎?

    只要是醫師,應該就看得懂,病患接受上述回答中黑體字所呈現的手術。

    需不需要另準備手術紀錄?

    理論上是不用,因為除非再把整本病歷調出來,否則看不到手術記錄。而且大概有四、五年以上了,不知會不會縮影存檔了。

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  • 十九
    Lv 4
    10 years ago

    你可以把整份出院病歷摘要給他

    出院病歷摘要中有一個欄位會是手術經過

    你寫的是住院治療及經過

    僅提到執行何項手術

    如果仍是不通過的話再去原醫院申請手術報告即可

    病歷保存年限為最後看診日往後算7年

    除非之後很久沒去該醫院看

    不然銷毀的機會不大

    就算已經掃描建檔也會有資料可以申請

    Source(s): 在病歷室工作的自己
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