1、中医病案英语书写格式中医病案英语书写格式 TCM RECORDINGRequirements for Requirements for Admission Note&Admission Note&Case DiscussionCase Discussion杨明山杨明山 Contents(Western M)1.Title 2.Glossary 3.Prevalence4.Manifestation5.Laboratory6.Other Diagnostic Aids7.Diagnosis 8.Treatment(EBM)Contents(TCM)Contents(TCM)1.TCM Thera
2、py Principle(理理):Method(法法):Formula(方方):主方主方 验方验方 Medicines(药药):主要药味主要药味-图谱图谱英文名与拉丁名英文名与拉丁名10.TCM(EBM):1.于于XX，24岁，女，未婚。岁，女，未婚。2.主诉：月经稀发主诉：月经稀发3年。年。3.现病史：患者现病史：患者3年前因自认为肥胖年前因自认为肥胖,又服又服药药,又节食又节食,后身体渐瘦后身体渐瘦,饮食少饮食少,胃口差胃口差,而后月经周期错后，一般而后月经周期错后，一般3至至5个月来潮个月来潮一次，行经一次，行经34天，经色淡天，经色淡,质稀质稀,无块，无块，经期伴下腹空坠隐痛，平素头晕
3、眼花经期伴下腹空坠隐痛，平素头晕眼花,疲乏无力，心悸。面色黄无华疲乏无力，心悸。面色黄无华,舌淡，舌淡，脉细。脉细。月经后期的定义及辨证论治。月经后期的病因病机,诊断与鉴别诊断1.1.定义：定义：2.2.月经周期延后月经周期延后7 7天以上，甚至天以上，甚至3 35 5月一行者。连续出现两个周期以上。月一行者。连续出现两个周期以上。3.3.本病首见于本病首见于金匮要略金匮要略 1.西医学的功能失调性子宫出血出现西医学的功能失调性子宫出血出现月经延后。月经延后。病因病机病因病机（肾虚（肾虚、血虚血虚、虚寒）虚寒）精血不足，冲任不充精血不足，冲任不充（虚（虚）（血寒（血寒、气滞）气滞）血行不畅，冲
4、任受阻（实）血行不畅，冲任受阻（实）血海不能按时满盈血海不能按时满盈 病因病机肾虚血虚虚寒实寒气滞虚 实冲任不充冲任不充血行不畅血行不畅血寒病因病机虚证先天肾气不足，先天肾气不足，损伤肾气，肾虚精亏损伤肾气，肾虚精亏房劳多产房劳多产 血少，冲任不足血少，冲任不足体质素弱，营血不足体质素弱，营血不足 营血营血 不足不足 久病失血，产育过多久病失血，产育过多 冲任不充冲任不充脾气虚弱，化源不足脾气虚弱，化源不足 血海不能血海不能素体阳虚素体阳虚 阳虚内寒，脏腑失于温养，生阳虚内寒，脏腑失于温养，生 按时满盈按时满盈久病伤阳久病伤阳 化失期，气虚血少，冲任不足化失期，气虚血少，冲任不足 病因病机实证
5、经期产后，外感寒邪经期产后，外感寒邪 血为寒凝血为寒凝 冲任欠通冲任欠通，血海，血海过服寒凉过服寒凉 运行涩滞运行涩滞 不能如期满溢不能如期满溢素多忧郁素多忧郁 血为气滞，运行不畅血为气滞，运行不畅 冲任受阻冲任受阻，血海，血海气机不宣气机不宣 不能如期满盈不能如期满盈病史：病史：禀赋不足，或感寒饮冷、情志不遂史。禀赋不足，或感寒饮冷、情志不遂史。临床表现临床表现:“定义定义”，连续，连续2 2个周期以上。个周期以上。检查：检查：妇检妇检:无异常或子宫稍小。无异常或子宫稍小。辅助检查：辅助检查：BBTBBT、性激素、性激素、B B超。超。诊断诊断鉴别诊断1.早孕2.妊娠期出血病证 辨证论治1.
6、辨证要点辨证要点：根据月经的根据月经的量、色、质量、色、质及全身及全身 证候结合舌脉以辨虚、实、寒、热。证候结合舌脉以辨虚、实、寒、热。1.治疗原则治疗原则：以调整周期为主，：以调整周期为主，虚者补之，实者泄之。虚者补之，实者泄之。妇科证候：妇科证候：周期延后，量少，色黯淡，质周期延后，量少，色黯淡，质清稀，或带下清稀。清稀，或带下清稀。全身证候：全身证候：肾虚证候。肾虚证候。舌舌 脉：脉：舌淡，苔薄白，脉沉细。舌淡，苔薄白，脉沉细。治治 法：法：补肾养血调经。补肾养血调经。方方 药：药：当归地黄饮当归地黄饮。熟地 山茱萸 山药 当归 杜仲 怀牛膝 甘草1 1、肾虚、肾虚2 2、血虚、血虚妇科
7、证候：妇科证候：周期延后，量少，色淡，质清周期延后，量少，色淡，质清 稀，或小腹绵绵作痛。稀，或小腹绵绵作痛。全身证候；全身证候；血虚证候。血虚证候。舌舌 脉：脉：舌淡，脉细弱。舌淡，脉细弱。治治 法：法：补血益气调经。补血益气调经。方方 药：药：大补元煎加川芎。大补元煎加川芎。人参人参 炙甘草炙甘草 当归当归 熟地熟地 杞子杞子 杜仲杜仲 山茱萸山茱萸 山药山药 3 3、血寒（、血寒（1 1）虚寒证）虚寒证妇科证候：妇科证候：月经延后，量少，色淡红，质清稀，月经延后，量少，色淡红，质清稀，小腹隐痛，喜暖喜按。小腹隐痛，喜暖喜按。全身证候：全身证候：虚寒证候。虚寒证候。舌舌 脉：脉：舌淡，苔白
8、，脉沉迟或细弱。舌淡，苔白，脉沉迟或细弱。治治 法：法：扶阳祛寒调经。扶阳祛寒调经。方方 药：药：温经汤温经汤金匮要略金匮要略或艾附暖宫丸或艾附暖宫丸 温经汤：温经汤：当归当归 川芎川芎 白芍白芍 人参人参 丹皮丹皮 甘草甘草 生姜生姜 麦冬麦冬 法夏法夏 阿胶阿胶 桂枝桂枝 吴茱萸吴茱萸（2 2）实寒证实寒证妇科证候：妇科证候：月经周期延后，量少，色黯有块，月经周期延后，量少，色黯有块，小腹冷痛拒按，得热痛减。小腹冷痛拒按，得热痛减。全身证候：全身证候：实寒实寒证候。证候。舌舌 脉：脉：舌淡黯，苔薄白，脉沉紧。舌淡黯，苔薄白，脉沉紧。治治 法：法：温经散温经散寒调经。寒调经。方方 药：药：温
9、经汤（温经汤（妇人大全良方妇人大全良方）。）。当归当归 川芎川芎 白芍白芍 人参人参 丹皮丹皮 甘草甘草 牛膝牛膝 肉桂肉桂 莪术莪术 4 4、气滞、气滞妇科证候：妇科证候：月经周期延后，量月经周期延后，量 少或正少或正 常，色黯红，或有血块，小腹胀痛。常，色黯红，或有血块，小腹胀痛。全身证候：全身证候：肝郁气滞证候。肝郁气滞证候。舌舌 脉：脉：舌正常或红，苔薄白或微黄，舌正常或红，苔薄白或微黄，脉弦或弦数。脉弦或弦数。治治 法：法：理气行滞调经理气行滞调经。方方 药：药：乌药汤。乌药汤。乌药乌药 香附香附 木香木香 当归当归 甘草甘草1.1.转归转归预后预后2.2.结语结语3.概念概念月经周
10、期延后月经周期延后7 7天以上，天以上，甚至甚至3 35 5月一行者。连续出现月一行者。连续出现两个周期以上。两个周期以上。4.辨证辨证虚、实。虚、实。5.治疗治疗调整周期为主。调整周期为主。Procedure1.翻译病史陈述，改写中西医病案首页翻译病史陈述，改写中西医病案首页 2.翻译病例讨论，作出中西医版本，其中包括翻译病例讨论，作出中西医版本，其中包括中医的辩证论治中医的辩证论治3.有兴趣者，改写成中西医查房版本有兴趣者，改写成中西医查房版本 4.国庆后交作业国庆后交作业5.课程末排练表演课程末排练表演TCM Part：虚拟添加虚拟添加 四诊包括四诊包括1.问诊：十问歌基础，须与辩证有关
11、者2.舌像3.脉象 理法方药摄理法方药摄1.病机2.治疗原则3.经典方剂4.一最主要药味5.加减药味6.摄生Western Medicine Part1.改写原版，缩短至改写原版，缩短至2500字母以内字母以内2.保留阳性资料保留阳性资料 确诊依据确诊依据3.保留阴性资料保留阴性资料 除外诊断除外诊断4.其余删除其余删除5.格式按照教学格式按照教学效果1.每组评选优秀写作一篇2.优秀者大幅度加分3.以优秀者为剧本，每组表演病例讨论4.邀请领导观摩，并拍录像中医病案书写格式中医病案书写格式中医病案书写格式中医病案书写格式中医病案书写格式中医病案书写格式Medical Record of TCMI
12、nspection,Auscultation and olfaction,Pulse-feeling and Palpation：clear consciousness and cooperation,painful expression,emotional fatigue,pallor complexion,pathologic leanness,dim complexion,eyeballs without icterus,puffy eyelid,dry lips with dim color,weak voice,short breath,occasional attacks of c
13、ough with sticky and whitish sputum which being 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.Picture Of the tongue:enlarged body of the tongu
14、e,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 regions,Irregularity in sequence of pulse beat.Physical examination:T:36.5;RP:96beats/min;R:24/min;BP:16/10k pa.Normal development,poor
15、 nourishment,unpalpation of superficial lymph node,distending jugular vein,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 cardiac apex and ha
16、rsh 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.Examination of nervous system:shallow nasolabial sulcus on the left and the strength of facial muscle on t
17、he left neveals weakness when exhibiting teeth,tongue protruded in the left,zero 1egree of muscle strength on the left 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.Le
18、ft-side Babinskis and Chaddook 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 manifested as dizziness,fall down on the ground,deviation of the mo
19、uth 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 consciousness,which indicated the attack involving the meridian(zhongjing).The presence of history of bizheng but not a diagnosis of bizheng,as the pa
20、tient has suffered from moving pain in the four extremities for twenty 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,and no unconsciousne
21、ss.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,depress feeling over the chest and shortness of breath;prolonged heart disease affected the spleen resu
22、lting in qi-deficiency of the heart and spleen,and failure of digestion and transportation,so leading to interiorly 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 resul
23、t in failure of clear and descending 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 night restlessness;retention of phlegm and heat leading
24、 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-yang failure to rise up marked by headache with heavy and distending sensation,and depress feeling over the chest and palpitation disorder of
25、 qi circulation leading to upwards of the stomach-qi,marked by poor appetite 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 phlegm,adde
26、d 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 obstructed the meridians and vessels,apoplexy occurred;involvement of meridians is confirmed as
27、no mental trouble.Systematic observation of the tongue,and pulse,and syndrome,the main disead part is the brain and 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;
28、involvement of meridian;heat-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 right-side internal carotid artery2.Rheumatic cardiac valvular
29、 disease,mitral stenosis and insufficiency heart failure II atrial fibrilation 中医病案英语书写格式中医病案英语书写格式 TCM RECORDING主诉、现病史、四诊主诉、现病史、四诊舌像与脉象舌像与脉象辩证分析辩证分析 =鉴别诊断鉴别诊断中医病机中医病机 =病理机制病理机制病史小结病史小结 =本人建议本人建议中医诊断中医诊断=Initial Impression of TCM建议建议1.国庆后交国庆后交2.以电子版交给组长以电子版交给组长3.各组长交给高秀飞各组长交给高秀飞4.参与第一，撰写质量第二参与第一，撰写质量第二5.中医鉴别诊断学中医鉴别诊断学06届某博士届某博士 著著6.鉴别诊断中医英语鉴别诊断中医英语 吴吴 健健 著著
