1+中医英语病案写作（一）.ppt

中医病案英语书写格式,TCMRECORDING,MedicalRecordofTCMInspection,Auscultationandolfaction,Pulse-feelingandPalpation：clearconsciousnessandcooperation,painfulexpression,emotionalfatigue,pallorcomplexion,pathologicleanness,dimcomplexion,eyeballswithouticterus,puffyeyelid,drylipswithdimcolor,weakvoice,shortbreath,occasionalattacksofcoughwithstickyandwhitishsputumwhichbeingdifficulttoexpectorate,fullydistendingjugularvein,edemainthelowerextremities,labialangledeviatedtotherightside,thetongueprotrudedintheleftside,hemiplegiaontheleft-sideof.thebody.PictureOfthetongue:enlargedbodyofthetongue,itprotrudedintheleftside,darkandpaletonguewithlightyellowandgreasyfuronthecentralpart.Pulsecondition:wiryandslippery,sunkenpulseatbothchiregions,Irregularityinsequenceofpulsebeat.Physicalexamination:T:36.5;RP:96beats/min;R:24/min;BP:16/10kpa.Normaldevelopment,poornourishment,unpalpationofsuperficiallymphnode,distendingjugularvein,scatteringbubblingsoundinthebaseofthelung;heartrate116beats/min,rrhythmia,unequalintensityofheartsounds,laterallyextendingcardiacdullnessarea,thunder-likediastolicmurmuraudibleinthecardiacapexandharshandblowingsystolicmurmurofthirddegree,hepatomegalyby4cminferiortotherib,6cminferiortothexiphoidprocess,middlingsoft,slightpress16ain,pittingedemainthelowextremities.Examinationofnervoussystem:shallownasolabialsulcusontheleftandthestrengthoffacialmuscleontheleftnevealsweaknesswhenexhibitingteeth,tongueprotrudedintheleft,zero1egreeofmusclestrengthontheleftextremitieswithlowermusculartension,painsensation,weakenedvibratorysensetothetuningforkintheleftextremities,tendonreflexindicatingmorehyperactivityontheleft.Left-sideBabinskisandChaddooksigns(+),others(-).Laboratorytests:routinetestsofblood,urine,stool,liverfunction,andHBsAgarenormal.Diagnosticdifferentiationandanalysis:Apoplexy(zhongfen)maybeconfirmedasthesuddenonsetmanifestedasdizziness,falldownontheground,deviationofthemouthandtongue,hemiplegiaontheleftsideofthebodYandthepresenceofdumpsbeforetheonset;themainsymptomandsignsofhemiplegiawithclearconsciousness,whichindicatedtheattackinvolvingthemeridian(zhongjing).Thepresenceofhistoryofbizhengbutnotadiagnosisofbizheng,asthepatienthassufferedfrommovingpaininthefourextremitiesfortwentyyears,butnojointspainlateryears;diagnosisofjiuzhengcouldnotbemadebecauseofclearconsciousness,andnocoldextremitiesitdiffersfromxianzhengasnospasmsofextremities,up-lookingofftheeyes,andnounconsciousness.Invadationofpathogenicwind,coldanddampinvolvedthemeridiansandvesselstoformbiofthemeridianandvesselsconsumedqileadingtohypoactivityoftheheart-yang,markedbypalpitation,depressfeelingoverthechestandshortnessofbreath;prolongedheartdiseaseaffectedthespleenresultinginqi-deficiencyoftheheartandspleen,andfailureofdigestionandtransportation,soleadingtointeriorlyproductionofphlegmaswellasprolongedbiattackedcollaterals,interiorlybloodstasisandexteriorlyofthebodyfluidproducedphlegmthephlegmobstructedthelungmeridianresultinfailureofclearanddescendingmarkedbycoughwithslightasthmaretentionofphlegmtransmittedtoheat,markedbystickyandthicksputumheattransmittedtothegall-bladdermarkedbydarkandscantyurine,disturbingthemindmarkedbynightrestlessness;retentionofphlegmandheatleadingtoobstructionoffu-organqimarkedbyyellowandgreasyfurcoatingandnomovementofbowelforfivedaysretentionofphlegmobstructedqiactivity,clear-yangfailuretoriseupmarkedbyheadachewithheavyanddistendingsensation,anddepressfeelingoverthechestandpalpitationdisorderofqicirculationleadingtoupwardsofthestomach-qi,markedbypoorappetitewithnausea,retentionofqiandinteriorlyofwaterdistributedtheskinandmuscleleadingtoedema.Thecasehasprolongeddiseasecoursewiththeconditionofinteriorblockadeofbloodstasisandretentionofphlegm,addedemotionalupsets,resultingintheupwarddisturbingoftheliver-yangandhyperactivityoftheinteriorwind,allthedisorderofqiandbloodinvolvedthebrain,andallthewind,phlegmandbloodstasisobstructedthemeridiansandvessels,apoplexyoccurred;involvementofmeridiansisconfirmedasnomentaltrouble.Systematicobservationofthetongue,andpulse,andsyndrome,themaindiseadpartisthebrainandrelatedtothelung,liver,spleenandstomach,thesyndromesbelongstodeficiencyofthehealthyqiandexcessofpathogenicfactors.Diagnosisforadmission:diagnosisofTCM:1.Apoplexy;involvementofmeridian;heat-phlegmresultinginexcessivefactorsinfu-organs,upwarddisturbingofwind-phlegm2.Palpitation：hypoactivityofheart-yang,qi:deficiencybloodstasisDiagnosisofWM:1.left-sidehemiplegiacerebralthrombosisright-sideinternalcarotidartery2.Rheumaticcardiacvalvulardisease,mitralstenosisandinsufficiencyheartfailureIIatrialfibrilation,主诉、现病史、四诊,主诉、现病史、其他病史下次教学,主诉现病史其他病史,中医病案书写格式四诊,中医病案书写格式四诊,舌像与脉象,中医病机=病理机制,辩证分析=鉴别诊断,中医诊断=InitialImpressionofTCM,中医病案书写格式,主诉：现病史：既往史：四诊：望诊:舌象：脉象:,辨证分析：中医诊断：诊