中醫(yī)病案英語書寫格式

1、中醫(yī)病案英語書寫格式,TCM RECORDING,Requirements for Admission Note & Case Discussion,楊明山,中醫(yī)雙語教學(xué) Bilingual TCM,中醫(yī)英語第一屬性是“醫(yī)”,中醫(yī)病案寫作 TCM Admission Note,開展實(shí)踐性中醫(yī)英語,Contents (Western M),Title Glossary PrevalenceManifestationLa

2、boratoryOther Diagnostic AidsDiagnosis Treatment (EBM),,簡單,,詳細(xì)以便與中醫(yī)比對(duì),Contents (TCM),Title (中醫(yī)病癥) Chronology (年代-名醫(yī)-名言-圖)Manifestation (偶字)Pathogenesis (病機(jī)，經(jīng)典引用)TCM Diagnosis (少而精) Inspection (舌象-圖譜) Inquiry、A&a

3、mp;O (可略)Palpation (脈證-圖譜-形象化),Contents (TCM),TCM Therapy 注:經(jīng)典引用不是為了文學(xué)Principle (理): 授課可略；病案則詳Method (法): 少而精Formula (方): 主方 驗(yàn)方Medicines (藥):主要藥味-圖譜英文名與拉丁名TCM (EBM):中醫(yī)在循證醫(yī)學(xué)評(píng)定中的地位與現(xiàn)代科研關(guān)系 (有則談之, 避免牽強(qiáng)附會(huì)),于XX，24歲，女，

4、未婚。主訴：月經(jīng)稀發(fā)3年?，F(xiàn)病史：患者3年前因自認(rèn)為肥胖,又服藥,又節(jié)食,后身體漸瘦,飲食少,胃口差,而后月經(jīng)周期錯(cuò)后，一般3至5個(gè)月來潮一次，行經(jīng)3~4天，經(jīng)色淡,質(zhì)稀,無塊，經(jīng)期伴下腹空墜隱痛，平素頭暈眼花,疲乏無力，心悸。面色黃無華,舌淡，脈細(xì)。,病 案,掌握:月經(jīng)后期的定義及辨證論治。熟悉：月經(jīng)后期的病因病機(jī),診斷與鑒別診斷,,月經(jīng)后期-目的要求,定義：月經(jīng)周期延后7天以上，甚至3～5月一行者。連續(xù)出現(xiàn)兩個(gè)周期以上。

5、本病首見于《金匱要略》 西醫(yī)學(xué)的功能失調(diào)性子宮出血出現(xiàn)月經(jīng)延后。,病因病機(jī) （腎虛、血虛、虛寒）精血不足，沖任不充（虛） （血寒、氣滯）血行不暢，沖任受阻（實(shí)） 血海不能按時(shí)滿盈,,,病因病機(jī),腎虛血虛虛寒實(shí)寒氣滯,,,,虛 實(shí),,沖任不充,,血行不暢,,血寒,病因病機(jī)——虛證,先天腎氣不足， 損傷腎氣，腎虛精

6、虧房勞多產(chǎn) 血少，沖任不足體質(zhì)素弱，營血不足 營血 不足 久病失血，產(chǎn)育過多 沖任不充脾氣虛弱，化源不足 血海不能素體陽虛 陽虛內(nèi)寒，臟腑失于溫養(yǎng)，生 按時(shí)滿盈久病傷陽 化失期，氣虛血少，沖任不足,,,,,,病因病機(jī)——實(shí)

7、證,經(jīng)期產(chǎn)后，外感寒邪 血為寒凝 沖任欠通，血海過服寒涼 運(yùn)行澀滯 不能如期滿溢素多憂郁 血為氣滯，運(yùn)行不暢 沖任受阻，血海氣機(jī)不宣 不能如期滿盈,,,,,病史：稟賦不足

8、，或感寒飲冷、情志不遂史。臨床表現(xiàn): “定義”，連續(xù)2個(gè)周期以上。檢查：婦檢: 無異?；蜃訉m稍小。 輔助檢查：BBT、性激素、B超。,診斷,鑒別診斷,早孕妊娠期出血病證,辨證論治,辨證要點(diǎn)：根據(jù)月經(jīng)的量、色、質(zhì)及全身 證候結(jié)合舌脈以辨虛、實(shí)、寒、熱。治療原則：以調(diào)整周期為主， 虛者補(bǔ)之，實(shí)者泄之。,婦科證候：周期延后，量少，色黯淡，質(zhì)清稀，或帶

9、下清稀。全身證候：腎虛證候。舌 脈：舌淡，苔薄白，脈沉細(xì)。治 法：補(bǔ)腎養(yǎng)血調(diào)經(jīng)。方 藥：當(dāng)歸地黃飲。 熟地 山茱萸 山藥 當(dāng)歸 杜仲 懷牛膝 甘草,1、腎虛,2、血虛,婦科證候：周期延后，量少，色淡，質(zhì)清 稀，或小腹綿綿作痛。全身證候；血虛證候。舌 脈：舌淡，脈細(xì)弱。治 法：補(bǔ)血益氣調(diào)經(jīng)。方 藥：大補(bǔ)元煎加川芎。

10、 人參 炙甘草 當(dāng)歸 熟地 杞子 杜仲 山茱萸 山藥,3、血寒（1）虛寒證婦科證候：月經(jīng)延后，量少，色淡紅，質(zhì)清稀，小腹隱痛，喜暖喜按。全身證候：虛寒證候。舌 脈：舌淡，苔白，脈沉遲或細(xì)弱。治 法：扶陽祛寒調(diào)經(jīng)。方 藥：溫經(jīng)湯《金匱要略》或艾附暖宮丸 溫經(jīng)湯：當(dāng)歸 川芎 白芍 人參 丹皮 甘草 生姜 麥冬 法夏

11、 阿膠 桂枝 吳茱萸,（2） 實(shí)寒證婦科證候：月經(jīng)周期延后，量少，色黯有塊，小腹冷痛拒按，得熱痛減。全身證候：實(shí)寒證候。舌 脈：舌淡黯，苔薄白，脈沉緊。治 法：溫經(jīng)散寒調(diào)經(jīng)。方 藥：溫經(jīng)湯（《婦人大全良方》）。 當(dāng)歸 川芎 白芍 人參 丹皮 甘草 牛膝 肉桂 莪術(shù),4 、氣滯婦科證候：月經(jīng)周期延后，量 少或正 常，色黯紅，或有血塊，小腹脹痛。全身證候

12、：肝郁氣滯證候。舌 脈：舌正常或紅，苔薄白或微黃， 脈弦或弦數(shù)。治 法：理氣行滯調(diào)經(jīng)。方 藥：烏藥湯。 烏藥 香附 木香 當(dāng)歸 甘草,轉(zhuǎn)歸預(yù)后結(jié)語概念——月經(jīng)周期延后7天以上，甚至3～5月一行者。連續(xù)出現(xiàn)兩個(gè)周期以上。辨證——虛、實(shí)。治療——調(diào)整周期為主。,Procedure,翻譯病史陳述，改寫中西醫(yī)病案首頁 翻譯病例討論，作出中西醫(yī)版本，

13、其中包括中醫(yī)的辯證論治有興趣者，改寫成中西醫(yī)查房版本 國慶后交作業(yè)課程末排練表演,TCM Part：虛擬添加,四診包括問診：《十問歌》基礎(chǔ)，須與辯證有關(guān)者舌像脈象,理法方藥攝病機(jī)治療原則經(jīng)典方劑一最主要藥味加減藥味攝生,Western Medicine Part,改寫原版，縮短至2500字母以內(nèi)保留陽性資料 – 確診依據(jù)保留陰性資料 – 除外診斷其余刪除格式按照教學(xué),效果,每組評(píng)選優(yōu)秀寫作一篇優(yōu)秀者大幅

14、度加分以優(yōu)秀者為劇本，每組表演病例討論邀請(qǐng)領(lǐng)導(dǎo)觀摩，并拍錄像,中醫(yī)病案書寫格式,中醫(yī)病案書寫格式,中醫(yī)病案書寫格式,Medical Record of TCMInspection, Auscultation and olfaction, Pulse-feeling and Palpation：clear consciousness and cooperation, painful expression, emotional fa

15、tigue, pallor complexion, pathologic leanness, dim complexion, eyeballs without icterus, puffy eyelid, dry lips with dim color, weak voice, short breath, occasional attacks of cough with sticky and whitish sputum which b

16、eing difficult to expectorate, fully distending jugular vein, edema in the lower extremities, labial angle deviated to the right side, the tongue protruded in the left side, hemiplegia on the left-side of. the body.Pict

17、ure Of the tongue: enlarged body of the tongue, it protruded in the left side, dark and pale tongue with light yellow and greasy fur on the central part.Pulse condition:wiry and slippery, sunken pulse at both chi regi

18、ons, Irregularity in sequence of pulse beat.Physical examination:T : 36.5℃; RP: 96beats/min; R: 24/min; BP: 16/10k pa.Normal development, poor nourishment, unpalpation of superficial lymph node, distending jugular vei

19、n, scattering bubbling sound in the base of the lung; heart rate 116 beats/min, rrhythmia, unequal intensity of heart sounds, laterally extending cardiac dullness area, thunder-like diastolic murmur audible in the cardia

20、c apex and harsh and blowing systolic murmur of third degree, hepatomegaly by 4cm inferior to the rib, 6cm inferior to the xiphoid process, middling soft, slight press 16ain, pitting edema in the low extremities.Examin

21、ation of nervous system : shallow nasolabial sulcus on the left and the strength of facial muscle on the left neveals weakness when exhibiting teeth, tongue protruded in the left, zero ~1egree of muscle strength on the l

22、eft extremities with lower muscular tension, pain sensation, weakened vibratory sense to the tuning fork in the left extremities, tendon reflex indicating more hyperactivity on the left. Left-side Babinskis and Chaddook

23、signs (+), others (-).Laboratory tests: routine tests of blood, urine, stool, liver function, and HBsAg are normal.Diagnostic differentiation and analysis:Apoplexy (zhongfen) may be confirmed as the sudden onset mani

24、fested as dizziness, fall down on the ground, deviation of the mouth and tongue, hemiplegia on the left side of the bodY and the presence of dumps before the onset; the main symptom and signs of hemiplegia with clear con

25、sciousness, which indicated the attack involving the meridian (zhongjing). The presence of history of bizheng but not a diagnosis of bizheng, as the patient has suffered from moving pain in the four extremities for twent

26、y years, but no joints pain later years; diagnosis of jiuzheng could not be madebecause of clear consciousness, and no cold extremities~ it differs from xianzheng as no spasms of extremities, up-looking off the eyes, an

27、d no unconsciousness.Invadation of pathogenic wind ,cold and damp involved the meridians and vessels to form bi of the meridian and vessels consumed qi leading to hypoactivity of the heart-yang, marked by palpitation, d

28、epress feeling over the chest and shortness of breath; prolonged heart disease affected the spleen resulting in qi-deficiency of the heart and spleen, and failure of digestion and transportation, so leading to interiorly

29、 production of phlegm as well as prolonged bi attacked collaterals, interiorly blood stasis and exteriorly of the body fluid produced phlegm the phlegm obstructed the lung meridian result in failure of clear and descendi

30、ng marked by cough with slight asthma retention of phlegm transmitted to heat, marked by sticky and thick sputum heat transmitted to the gall- bladder marked by dark and scanty urine, disturbing the mind marked by ni

31、ght restlessness; retention of phlegm and 'heat leading to obstruction of fu-organ qi marked by yellow and greasy fur coating and no movement of bowel for five days retention of phlegm obstructed qi activity, clear-y

32、ang failure to rise up marked by headache with heavy and distending sensation , and depress feeling over the chest and palpitation ~disorder of qi circulation leading to upwards of the stomach-qi, marked by poor appetite

33、 with nausea, retention of qi and interiorly of water distributed 'the skin and muscle leading to edema. The case has prolonged disease course with the condition of interior blockade of blood stasis and retention of

34、phlegm, added emotional upsets, resulting in the upward disturbing of the liver-yang and hyperactivity of the interior wind, all the disorder of qi and blood involved the brain, and all the wind, phlegm and blood stasis

35、obstructed the meridians and vessels, apoplexy occurred ; involvement of meridians is confirmed as no mental trouble. Systematic observation of the tongue, and pulse, and syndrome, the main disea~d part is the brain and

36、related to the lung, liver, spleen and stomach, the syndromes belongs to deficiency of the healthy qi and excess of pathogenic factors.Diagnosis for admission: diagnosis of TCM: 1. Apoplexy; involvement of meridian; h

37、eat-phlegm resulting in excessive factors in fu-organs, upward disturbing of wind-phlegm2. Palpitation：hypoactivity of heart-yang, qi:deficiency blood stasisDiagnosis of WM: 1. left-side hemiplegia cerebral thrombosis

38、 right-side internal carotid artery2. Rheumatic cardiac valvular disease, mitral stenosis and insufficiency heart failure II atrial fibrilation,中醫(yī)病案英語書寫格式,TCM RECORDING,主訴、現(xiàn)病史、四診,舌像與脈象,辯證分析 = 鑒別診斷,中醫(yī)病機(jī) = 病理機(jī)制,病史小結(jié) = 本人建