1、英文交班,五段四病房,Ward report,Ward five/four N5/4 Total patient :forty-one 总数:41 Admission :two 新入院:2 Transferred in :one 转入:1 Discharge :two 出院:2 Operation :three 手术:3 Transferred out :one 转出:1,侧弯常见诊断与手术名称,常见诊断:先天性侧弯 congenital scoliosis 继发性侧弯secondary scoliosis特发性侧弯 idiopathic scoliosis成人侧弯adult scoliosi
2、s,常见手术名称: 前路松解后路矫形内固定植骨融合术anterior release and posterior correction with internal fixation and bone graft fusion半椎体切除resection of hemivertebra,腰椎病变常见诊断与手术名称,常见诊断:腰椎间盘突出 disc protrusion腰椎管狭窄 Spinal stenosis,常见手术名称:腰椎间盘摘除 discectomy of intervertebral disc腰椎管减压内固定植骨Lumbar spinal decompression with inte
3、rnal fixation and bone graft fusion,颈椎病常见诊断与手术名称,常见诊断: 神经根型 cervical spondylotic radiculopathy 脊髓型cervical spondylotic myelopathy 椎动脉型 vertebral artery type of cervical spondylosis 交感型sympathetic type of cervical spondylosis 混合型compound type of cervical spondylosis,常见手术名称:前路椎体次全切anterior corpectomy
4、of C*间盘摘除discectomy of 后路单(双)开门椎管扩大成形术posterior single-door laminoplasty of C*-*,侧弯病人,Bed 22 wangxin 13-year-old boy ,this morning he will undergo anterior correction with isola internal fixation and bone graft fusion under general aneasthesia. This morning his temperature was thirty-six point seven
5、 centigrade. 22床 王欣 13岁男孩，今日上午将在全麻下行前路矫形isola内固定植骨融合术今晨体温是36.7度,侧弯术后,Bed 22 wangxin 13-year-old boy ,yesterday he underwent anterior correction with isola internal fixation and bone graft fusion under general aneasthesia. He returned to ward awaken at two and a quarter pm with right senses, the move
6、ment and sense of all limbs was normal . This morning, his temperature was thirty-seven point five centigrade,the drainage was two hundred and thirty millimeter ,the thoracic drainage was two hundred millimeter , fluctuating was obvious . 22床 王欣 13岁男孩，昨日在全麻下行前路矫形isola内固定植骨融合术术后两点十五返病室时神志清楚,四肢感觉活动好,今
7、晨体温37.5度,伤口引流230ml,胸引起200ml,波动好.,腰椎手术,Bed eleven yangxinyu sixty-eight-year-old female this morning she will undergo posterior decompression with TSRH internal fixation and bone graft fusion under general aneasthesia . This morning her temperature was thirty-six point two . 11床 杨星语 68岁女性.今晨将在全;麻下行腰椎
8、后路减压TSRH内固定植骨融合术.今晨体温是36.2度.,腰椎术后,Bed eleven yangxinyu sixty-eight-year-old female yesterday she underwent posterior decompression with TSRH internal fixation and bone graft fusion under general aneasthesia she returned to ward at one pm. The movement and sense of all limbs is normal except. This mo
9、rning her temperature was thirty-seven point two centigrade ,the drainage was one hundred millimeter. 11床 杨星语 68岁女性.昨日在全麻下行腰椎后路减压TSRH内固定植骨融合术.1PM回病室,四肢感觉活动好,今晨体温是37.2度.引流100ML.,颈椎病,Bed ten yangliu forty-six-year-old male this afternoon he will undergo posterior single-door laminoplasty of C3-7 under
10、 general aneasthesia.This morning his temperature was thirty-six point three centigrade. 10床 杨柳 男,46岁 今天下午将在全麻下行颈后路C3-7单开门扩大成形术.今晨体温36.3度.,颈椎病术后,Bed ten yangliu forty-six-year-old male underwent posterior C3-7 single-door laminoplasty he returned to ward at 7PM,the movement and sense of both lower l
11、imbs is powerless,he complained of pain(paralysis) on left upper limb . This morning his temperature was thirty-seven point six ,the drainage was fifty millimeter . The movement and sense of all limbs changed unconspicuously. 10床 杨柳 男,46岁 昨天下午在全麻下行颈后路C3-7单开门扩大成形术.术后7PM返病室神志清楚,双下肢感觉活动弱,主诉左上肢疼痛(麻木),今晨
12、体温37.6度,引流50ML,四肢感觉活动无明显变化.,高热病人,Bed forty weifang post operation of resection of L3 with CDH internal fixation and bone graft fusion four days . Yesterday evening her temperature was thirty-nine point seven , we gave her one over three indomethacin and supply liquor , this morning her temperature w
13、as thirty-eight point five centigrade. 40床 魏芳 L3后路减压CDH内固定植骨相互依赖融合术后4天,昨晚体温39.7度,遵嘱查血培养,给予1/3消炎痛栓置肛,补液.今晨体温38.5度.,血压高,Bed sixteen lilu yesterday afternoon she underwent myelography under local aneasthesia. The movement and sense of all limbs was normal . Blood pressure was one hundred and eighty ove
14、r one hundred millimeter mercury. Blood pressure was down to one hundred and forty over eighty-five mmhg by taking nifedipine two hours later. This morning her blood pressure was one hundred and sixty over ninety-five mmhg. 16床 李璐 昨天下午在局麻下行脊髓造影术,返病室时四肢感觉活动好,血压180/100mmhg,口服心痛定一片,两小时后复测140/85mmhg,今晨血
15、压160/95mmhg.,输血,Bed thirty he underwent posterior correction with isola internal fixation under GA. His drainage was four hundred and fifty ml in two hours . One unit of reptilase was given intramuscularly ,another unit was given intraveinly immediately , along with transfusion of red blood cells tw
16、o units . The result of blood routine showed 血红蛋白 ninety-two mg/dl. 30床 昨日在全麻下行后路矫形isola内固定植骨术,两小时倒引流450ml,遵嘱给予立止血一个单位肌注,一个单位入壶.输入两个单位红细胞.今晨血常规结果示血红蛋白92mg/dl.,疼痛,Bed thirty he underwent posterior correction with isola internal fixation under GA. He complained of severe pain on the wound, the pain al
17、leviated much by injecting dolantin 50 milligrams and promethazine 25 mg intramuscularly.30床 昨日在全麻下行后路矫形isola内固定,主诉伤口疼,肌注D+P后疼痛减轻.,血糖高,Bed twenty the diagnosis is disc protrusion .blood sugar after dinner was 298mg/dl and decreased to 232mg/dl by injecting four units insulin . This morning the fasti
18、ng blood sugar was 225mg/dl. 20床 诊断是腰椎间盘突出.餐后血糖是298mg/dl,注射4个单位胰岛素后复测血糖232mg/dl,今晨空腹血糖为225mg/dl,出入量,Post operation of lumbar spinal decompression and internal fixation 5days ,yesterday the patients intake was three thousand two hundred ml, urine volume was two thousand nine hundred and eighty ml in 24 hours. 腰椎减压术后5天,昨日全天入量3200ml,尿量2980ml.,
