中醫(yī)病案英語書寫格式培訓(xùn)課件

1、中醫(yī)病案英語書寫格式中醫(yī)病案英語書寫格式Requirements for Admission Note & Case Discussion楊明山中醫(yī)病案英語書寫格式2Requirements for Admission Not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)病案英語書寫格式3中醫(yī)雙語教學(xué) Bilingual TCM中醫(yī)英語第一屬性是中醫(yī)病案寫作 TCM Admission Note開展實踐性中醫(yī)英語中醫(yī)病案英語書寫格式4中醫(yī)病案寫作 TCM Admission Note開展實踐Contents (Western M)Title Glossary Preval

2、enceManifestationLaboratoryOther Diagnostic AidsDiagnosis Treatment (EBM)簡單詳細以便與中醫(yī)比對中醫(yī)病案英語書寫格式5Contents (Western M)Title 簡單詳細Contents (TCM)Title (中醫(yī)病癥) Chronology (年代-名醫(yī)-名言-圖)Manifestation (偶字)Pathogenesis (病機，經(jīng)典引用)TCM Diagnosis (少而精) Inspection (舌象-圖譜) Inquiry、A&O (可略)Palpation (脈證-圖譜-形象化) 中醫(yī)病案英語書寫

3、格式6Contents (TCM)Title (中醫(yī)病癥) 中醫(yī)病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)評定中的地位與現(xiàn)代科研關(guān)系 (有則談之, 避免牽強附會)中醫(yī)病案英語書寫格式7Contents (TCM)TCM Therapy 注:經(jīng)典于XX，24歲，女，未婚。主訴：月經(jīng)稀發(fā)3年?，F(xiàn)病史：患者3年前因自認為肥胖,又服藥,又節(jié)食,后身體漸瘦,飲食少,胃

4、口差,而后月經(jīng)周期錯后，一般3至5個月來潮一次，行經(jīng)34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。 病 案中醫(yī)病案英語書寫格式8于XX，24歲，女，未婚。病 案中醫(yī)病案英語書寫格式8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,診斷與鑒別診斷月經(jīng)后期-目的要求中醫(yī)病案英語書寫格式9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, 定義：月經(jīng)周期延后7天以上，甚至35月一行者。連續(xù)出現(xiàn)兩個周期以上。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。中醫(yī)病案英語書寫格式10 定義：中醫(yī)病案英語書寫格式10病因病

5、機 （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） 血海不能按時滿盈 中醫(yī)病案英語書寫格式11病因病機 （腎虛、血虛、虛寒）精血不足，沖任不充（虛） 病因病機腎虛血虛虛寒實寒氣滯虛 實沖任不充血行不暢血寒中醫(yī)病案英語書寫格式12病因病機腎虛虛 實沖任不充血行不暢血寒中醫(yī)病案病因病機虛證先天腎氣不足， 損傷腎氣，腎虛精虧房勞多產(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 按時滿盈久病傷陽 化失期，氣虛血少，沖任不足 中醫(yī)病案英語書寫格式13病因病機虛證中醫(yī)病案英

6、語書寫格式13病因病機實證經(jīng)期產(chǎn)后，外感寒邪 血為寒凝 沖任欠通，血海過服寒涼 運行澀滯 不能如期滿溢素多憂郁 血為氣滯，運行不暢 沖任受阻，血海氣機不宣 不能如期滿盈中醫(yī)病案英語書寫格式14病因病機實證中醫(yī)病案英語書寫格式14病史：稟賦不足，或感寒飲冷、情志不遂史。臨床表現(xiàn): “定義”，連續(xù)2個周期以上。檢查：婦檢: 無異?；蜃訉m稍小。 輔助檢查：BBT、性激素、B超。 診斷中醫(yī)病案英語書寫格式15病史：稟賦不足，或感寒飲冷、情志不遂史。臨床表現(xiàn): “定鑒別診斷早孕妊娠期出血病證中醫(yī)病案英語書寫格式16鑒別診斷中醫(yī)病案英語書寫格式16 辨證論治辨證要點：根據(jù)月經(jīng)的量、色、質(zhì)及全身 證候結(jié)合舌

7、脈以辨虛、實、寒、熱。治療原則：以調(diào)整周期為主， 虛者補之，實者泄之。 中醫(yī)病案英語書寫格式17 辨證論治辨證要點：根據(jù)月經(jīng)的量、色、質(zhì)及全身中醫(yī)病案 婦科證候：周期延后，量少，色黯淡，質(zhì)清稀，或帶下清稀。全身證候：腎虛證候。舌 脈：舌淡，苔薄白，脈沉細。治 法：補腎養(yǎng)血調(diào)經(jīng)。方 藥：當歸地黃飲。 熟地 山茱萸 山藥 當歸 杜仲 懷牛膝 甘草1、腎虛中醫(yī)病案英語書寫格式18 婦科證候：周期延后，量少，色黯淡，質(zhì)清稀，或帶下清稀。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，脈細弱。治 法：補血益氣調(diào)經(jīng)。方 藥：大補元煎加川芎。 人參 炙甘草

8、 當歸 熟地 杞子 杜仲 山茱萸 山藥中醫(yī)病案英語書寫格式192、血虛婦科證候：周期延后，量少，色淡，質(zhì)清中醫(yī)病案英語書寫 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：當歸 川芎 白芍 人參 丹皮 甘草 生姜 麥冬 法夏 阿膠 桂枝 吳茱萸中醫(yī)病案英語書寫格式20 3、血寒（1）虛寒證婦科證候：月經(jīng)延后，量少（2） 實寒證婦科證候：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：實寒證候。舌 脈：舌淡黯，苔薄白，脈沉緊。治

9、 法：溫經(jīng)散寒調(diào)經(jīng)。方 藥：溫經(jīng)湯（婦人大全良方）。 當歸 川芎 白芍 人參 丹皮 甘草 牛膝 肉桂 莪術(shù) 中醫(yī)病案英語書寫格式21（2） 實寒證婦科證候：月經(jīng)周期延后，量少，色黯有塊，小腹 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：肝郁氣滯證候。舌 脈：舌正?；蚣t，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 當歸 甘草中醫(yī)病案英語書寫格式22 4 、氣滯婦科證候：月經(jīng)周期延后轉(zhuǎn)歸預(yù)后結(jié)語概念月經(jīng)周期延后7天以上，甚至35月一行者。連續(xù)出現(xiàn)兩個周期以上。辨證虛、實。治療調(diào)整周期為主。中醫(yī)病案英語書寫格式23

10、轉(zhuǎn)歸預(yù)后中醫(yī)病案英語書寫格式23Procedure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，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)課程末排練表演中醫(yī)病案英語書寫格式24Procedure翻譯病史陳述，改寫中西醫(yī)病案首頁 中醫(yī)病案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治療原則經(jīng)典方劑一最主要藥味加減藥味攝生中醫(yī)病案英語書寫格式25TCM Part：虛擬添加四診包括理法方藥攝中醫(yī)病案英語書寫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

11、除外診斷其余刪除格式按照教學(xué)中醫(yī)病案英語書寫格式26Western Medicine Part改寫原版，縮短至2中醫(yī)病案英語書寫格式培訓(xùn)課件中醫(yī)病案書寫格式中醫(yī)病案英語書寫格式28中醫(yī)病案書寫格式中醫(yī)病案英語書寫格式28中醫(yī)病案書寫格式中醫(yī)病案英語書寫格式29中醫(yī)病案書寫格式中醫(yī)病案英語書寫格式29中醫(yī)病案書寫格式中醫(yī)病案英語書寫格式30中醫(yī)病案書寫格式中醫(yī)病案英語書寫格式30Medical Record of TCMInspection, Auscultation and olfaction, Pulse-feeling and Palpation：clear consciousness a

12、nd 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 cough with sticky and whitish sputum which being difficult to expectorate, f

13、ully 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 tongue, it protruded in the left side, dark and pale tongue with light ye

14、llow 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 nourishment, unpalpation of superficial lymph node, di

15、stending 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 harsh and blowing systolic murmur of third degree

16、, 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 the left neveals weakness when exhibiting

17、 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. Left-side Babinskis and Chaddook sig

18、ns (+), 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 mouth and tongue, hemipl

19、egia 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 patient has suffer

20、ed 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 unconsciousness.Invadati

21、on 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 resulting i

22、n 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 result in

23、 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

25、 of 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 phleg

26、m, 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 obstructed the meridians and vessels, apoplexy occurred ; involvement of meridians is

27、 confirmed as 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; involvement of meridian; heat-phlegm resulting in excessive facto