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1、医疗美容医院病历号:隆乳术手术记录姓名Name年龄Age性别Sex9iM女F病历号MRN手术日期Dateofoperation手术医师MainPhysician麻解医,Anaesthesia助理医师Assistphysician洗手护士Hand-washednurse巡回护士OndUtynUrSC手术日期:年月日Opcniiiondiitc:yymmdd开始时间:时分Startingtime:hourmunitc结束时间:时分Finishingtime:hourmunitc手术名称IIM1.术SUgyCnbrcartenhaDCement术前检杳Examinationbeforeopera1.
2、ion1.专科检查Majorcheck乳房大小估计:Estimatesizeofbreast左恻ICfISidem1.右(HnghiSidCm1.两乳房外形:Out1.ineofapairofbivast口对称Match口不对称Unmatched乳房下垂:Masiopiosis口有Yes0无No孔头在乳房下皱翻同一水平以上(以下)Ni即kdrapeonthesame)cvc1.(be1.ow)undcrbreast乳头分泌物:Sccrctionofmpp1.c有YeS口无NO乳房红、肿、热Red、swe1.,hoofthebreast口有YeS口无NO乳房皮肤见!痕:SCarOn岷SkinDf
3、bTeind口有Yes口无No在on部位PoSiIOn外形OU1.1.i正大小SiZe孔房肿块:Breastpuff未扪及NO扪及Yrs质地TeXhIrr软M-t硬hard边缘Edfic消C1.car不清notCICarTK痛tenderness无NO有Ycs肿块部位Positionofswe1.1.:大big小Sma1.1.股下淋巴结:Oxier未扪及No扪及YeSi质地TeXuIm大小SiZe边缘清(不清.c1.earCdSc(Undcar)能(不能)移动(CanOmovc卿弗M形:Abnorma1.ityofthrax口无NO-ffYcs在On部位POSiIiOn何简形howabnorm
4、a1.胸麻大小:Sizeofthorax般乳头胸围chestcircumferetepassingnipp1.em羟第4肋间胸围ChestCinrumferetKepassing4h11hcm经孔房卜,绿皮肤皱褶Passingruff1.eskinunderbreastIwctma”cm2血常规B1.oodroutinc有(无)异常异常项目:3 .凝血Ift原时间Timeofthrombin有(无)异常异常项目:4 .心电图E1.ecirocardiogram有无异常异常项目:5 .其他others有(无异常异常项目:手术记录OpentiionRecords(乳处切开:Cuttingthear
5、edamammae1 .全身麻醉、龄脓麻醉加局部麻醉下、平卧位,常规消毒铺巾.Pftjs1.rationundergenera1.,veinand1.oca1.anaeihesia,rgu1.ardisinfectionoftowe1.2 .乳八八.9点(或,点)向下切口,长约Cm,切开皮肤、皮卜.丝孔腺(乳腺边缘)达胸大肌筋胰,沿胸大肌纤维方向分离该肌,约45cm用手指在胸大肌层下钝性分熟出腕隙.内至胸科旁,外至被散前税,下达乳房下缘下方约IcmCuttingdownside3pomtsonarcohmammae,9points(orpointroint)1.c11gthcn.Cuti11gOPentheskin1HYPOthroughga1.actopborc(cdc)toCctopcctorahsfascia,separating1.acunaundertheIayCrCCtQPertoeSbyusingfincsoi11sinsideofchestbonc.outtoantcnorax1.aIineJowntobreastdownsideaboutIcm医疗美容医院