2+中医英语病案写作（二）.ppt

1、中医病案英语书写格式,TCM RECORDING,Requirements for Admission Note RP: 96beats/min; R: 24/min; BP: 16/10k pa. Normal development, poor 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 in

2、tensity 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, hepatomegaly by 4cm inferior to the rib, 6cm inferior to the xiphoid process, middling soft, slight press 16ain, pittin

3、g 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 teeth, tongue protruded in the left, zero 1egree of muscle strength on the left extremities with lower muscular tension

4、, 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 signs (+), others (-). Laboratory tests: routine tests of blood, urine, stool, liver function, and HBsAg are normal. Diagno

5、stic 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, hemiplegia on the left side of the bodY and the presence of dumps before the onset; the main symptom and signs of hemiplegi

6、a 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 suffered from moving pain in the four extremities for twenty years, but no joints pain later years; diagnosis of jiuzheng c

7、ould not be made because of clear consciousness, and no cold extremities it differs from xianzheng as no spasms of extremities, up-looking off the eyes, and no unconsciousness. Invadation of pathogenic wind ,cold and damp involved the meridians and vessels to form bi of the meridian and vessels cons

8、umed 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 in qi-deficiency of the heart and spleen, and failure of digestion and transportation, so leading to interiorly prod

9、uction 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 descending marked by cough with slight asthma retention of phlegm transmitted to heat, marked

10、 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 to obstruction of fu-organ qi marked by yellow and greasy fur coating and no movement of bowel for five days reten

11、tion 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 qi circulation leading to upwards of the stomach-qi, marked by poor appetite with nausea, retention of qi and i

12、nteriorly 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, added emotional upsets, resulting in the upward disturbing of the liver-yang and hyperactivity of the interior w

13、ind, 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 no mental trouble. Systematic observation of the tongue, and pulse, and syndrome, the main disead par

14、t 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 factors in fu-organs, upward disturbing of wind-phlegm 2. Palpitation：hypoactivity of heart-yang, qi:deficiency blood stasis Diagnosis of WM: 1. left-side hemiplegia cerebral thrombosis right-side internal carotid artery 2. Rheumatic cardiac valvular disease, mitral stenosis and insufficiency heart fa