中医病案英语书写格式培训课件

1、中医病案英语书写格式中医病案英语书写格式Requirements for Admission Note & Case Discussion杨明山中医病案英语书写格式2Requirements for Admission Not中医双语教学 Bilingual TCM中医英语第一属性是“医”中医病案英语书写格式3中医双语教学 Bilingual TCM中医英语第一属性是中医病案写作 TCM Admission Note开展实践性中医英语中医病案英语书写格式4中医病案写作 TCM Admission Note开展实践Contents (Western M)Title Glossary Preval

2、enceManifestationLaboratoryOther Diagnostic AidsDiagnosis Treatment (EBM)简单详细以便与中医比对中医病案英语书写格式5Contents (Western M)Title 简单详细Contents (TCM)Title (中医病症) Chronology (年代-名医-名言-图)Manifestation (偶字)Pathogenesis (病机，经典引用)TCM Diagnosis (少而精) Inspection (舌象-图谱) Inquiry、A&O (可略)Palpation (脉证-图谱-形象化) 中医病案英语书写

3、格式6Contents (TCM)Title (中医病症) 中医病Contents (TCM)TCM Therapy 注:经典引用不是为了文学Principle (理): 授课可略；病案则详Method (法): 少而精Formula (方): 主方 验方Medicines (药):主要药味-图谱英文名与拉丁名TCM (EBM):中医在循证医学评定中的地位与现代科研关系 (有则谈之, 避免牵强附会)中医病案英语书写格式7Contents (TCM)TCM Therapy 注:经典于XX，24岁，女，未婚。主诉：月经稀发3年。现病史：患者3年前因自认为肥胖,又服药,又节食,后身体渐瘦,饮食少,胃

4、口差,而后月经周期错后，一般3至5个月来潮一次，行经34天，经色淡,质稀,无块，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,舌淡，脉细。 病 案中医病案英语书写格式8于XX，24岁，女，未婚。病 案中医病案英语书写格式8掌握:月经后期的定义及辨证论治。熟悉：月经后期的病因病机,诊断与鉴别诊断月经后期-目的要求中医病案英语书写格式9掌握:月经后期的定义及辨证论治。熟悉：月经后期的病因病机, 定义：月经周期延后7天以上，甚至35月一行者。连续出现两个周期以上。本病首见于金匮要略 西医学的功能失调性子宫出血出现月经延后。中医病案英语书写格式10 定义：中医病案英语书写格式10病因病

5、机 （肾虚、血虚、虚寒）精血不足，冲任不充（虚） （血寒、气滞）血行不畅，冲任受阻（实） 血海不能按时满盈 中医病案英语书写格式11病因病机 （肾虚、血虚、虚寒）精血不足，冲任不充（虚） 病因病机肾虚血虚虚寒实寒气滞虚 实冲任不充血行不畅血寒中医病案英语书写格式12病因病机肾虚虚 实冲任不充血行不畅血寒中医病案病因病机虚证先天肾气不足， 损伤肾气，肾虚精亏房劳多产 血少，冲任不足体质素弱，营血不足 营血 不足 久病失血，产育过多 冲任不充脾气虚弱，化源不足 血海不能素体阳虚 阳虚内寒，脏腑失于温养，生 按时满盈久病伤阳 化失期，气虚血少，冲任不足 中医病案英语书写格式13病因病机虚证中医病案英

6、语书写格式13病因病机实证经期产后，外感寒邪 血为寒凝 冲任欠通，血海过服寒凉 运行涩滞 不能如期满溢素多忧郁 血为气滞，运行不畅 冲任受阻，血海气机不宣 不能如期满盈中医病案英语书写格式14病因病机实证中医病案英语书写格式14病史：禀赋不足，或感寒饮冷、情志不遂史。临床表现: “定义”，连续2个周期以上。检查：妇检: 无异常或子宫稍小。 辅助检查：BBT、性激素、B超。 诊断中医病案英语书写格式15病史：禀赋不足，或感寒饮冷、情志不遂史。临床表现: “定鉴别诊断早孕妊娠期出血病证中医病案英语书写格式16鉴别诊断中医病案英语书写格式16 辨证论治辨证要点：根据月经的量、色、质及全身 证候结合舌

7、脉以辨虚、实、寒、热。治疗原则：以调整周期为主， 虚者补之，实者泄之。 中医病案英语书写格式17 辨证论治辨证要点：根据月经的量、色、质及全身中医病案 妇科证候：周期延后，量少，色黯淡，质清稀，或带下清稀。全身证候：肾虚证候。舌 脉：舌淡，苔薄白，脉沉细。治 法：补肾养血调经。方 药：当归地黄饮。 熟地 山茱萸 山药 当归 杜仲 怀牛膝 甘草1、肾虚中医病案英语书写格式18 妇科证候：周期延后，量少，色黯淡，质清稀，或带下清稀。2、血虚妇科证候：周期延后，量少，色淡，质清 稀，或小腹绵绵作痛。全身证候；血虚证候。舌 脉：舌淡，脉细弱。治 法：补血益气调经。方 药：大补元煎加川芎。 人参 炙甘草

8、 当归 熟地 杞子 杜仲 山茱萸 山药中医病案英语书写格式192、血虚妇科证候：周期延后，量少，色淡，质清中医病案英语书写 3、血寒（1）虚寒证妇科证候：月经延后，量少，色淡红，质清稀，小腹隐痛，喜暖喜按。全身证候：虚寒证候。舌 脉：舌淡，苔白，脉沉迟或细弱。治 法：扶阳祛寒调经。方 药：温经汤金匮要略或艾附暖宫丸 温经汤：当归 川芎 白芍 人参 丹皮 甘草 生姜 麦冬 法夏 阿胶 桂枝 吴茱萸中医病案英语书写格式20 3、血寒（1）虚寒证妇科证候：月经延后，量少（2） 实寒证妇科证候：月经周期延后，量少，色黯有块，小腹冷痛拒按，得热痛减。全身证候：实寒证候。舌 脉：舌淡黯，苔薄白，脉沉紧。治

9、 法：温经散寒调经。方 药：温经汤（妇人大全良方）。 当归 川芎 白芍 人参 丹皮 甘草 牛膝 肉桂 莪术 中医病案英语书写格式21（2） 实寒证妇科证候：月经周期延后，量少，色黯有块，小腹 4 、气滞妇科证候：月经周期延后，量 少或正 常，色黯红，或有血块，小腹胀痛。全身证候：肝郁气滞证候。舌 脉：舌正常或红，苔薄白或微黄， 脉弦或弦数。治 法：理气行滞调经。方 药：乌药汤。 乌药 香附 木香 当归 甘草中医病案英语书写格式22 4 、气滞妇科证候：月经周期延后转归预后结语概念月经周期延后7天以上，甚至35月一行者。连续出现两个周期以上。辨证虚、实。治疗调整周期为主。中医病案英语书写格式23

10、转归预后中医病案英语书写格式23Procedure翻译病史陈述，改写中西医病案首页 翻译病例讨论，作出中西医版本，其中包括中医的辩证论治有兴趣者，改写成中西医查房版本 国庆后交作业课程末排练表演中医病案英语书写格式24Procedure翻译病史陈述，改写中西医病案首页 中医病案TCM Part：虚拟添加四诊包括问诊：十问歌基础，须与辩证有关者舌像脉象理法方药摄病机治疗原则经典方剂一最主要药味加减药味摄生中医病案英语书写格式25TCM Part：虚拟添加四诊包括理法方药摄中医病案英语书写Western Medicine Part改写原版，缩短至2500字母以内保留阳性资料 确诊依据保留阴性资料

11、除外诊断其余删除格式按照教学中医病案英语书写格式26Western Medicine Part改写原版，缩短至2中医病案英语书写格式培训课件中医病案书写格式中医病案英语书写格式28中医病案书写格式中医病案英语书写格式28中医病案书写格式中医病案英语书写格式29中医病案书写格式中医病案英语书写格式29中医病案书写格式中医病案英语书写格式30中医病案书写格式中医病案英语书写格式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