中医病案英语书写格式 TCM RECORDING

Requirements for Admission Note & Case Discussion 杨明山

中医双语教学 Bilingual TCM 中医英语第一属性是“医”

中医病案写作 TCM Admission Note 开展实践性中医英语

Contents (Western M) 简单 详细以便与中医比对 Title Glossary Prevalence Manifestation Laboratory Other Diagnostic Aids Diagnosis Treatment (EBM) 简单 详细以便与中医比对

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)

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)

病 案 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,胃口差,而后月经周期错后，一般3至5个月来潮一次，行经3~4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。

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 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

月经周期延后7天以上，甚至3～5月一行者。连续出现两个周期以上。 定义： 月经周期延后7天以上，甚至3～5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。 相当于1、排卵型功血中的黄体不健。2、盆腔炎所致的子宫出血。

病因病机 （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 病因病机 （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

肾虚 血虚 虚寒实寒 气滞 病因病机 冲任不充 虚 实 血寒 血行不畅

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 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

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 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

诊断 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。

鉴别诊断 早孕 妊娠期出血病证

辨证论治 辨证要点：根据月经的量、色、质及全身 证候结合舌脉以辨虚、实、寒、热。 治疗原则：以调整周期为主， 虚者补之，实者泄之。

1、肾虚 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

2、血虚 妇科证候：周期延后，量少，色淡，质清 全身证候；血虚证候。 舌 脉：舌淡，脉细弱。 治 法：补血益气调经。 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 当归 熟地 杞子 杜仲 山茱萸 山药

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

（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 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

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

转归预后 结语 概念——月经周期延后7天以上，甚至3～5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。

Procedure 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

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

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 – 除外诊断 其余删除 格式按照教学

效果 每组评选优秀写作一篇 优秀者大幅度加分 以优秀者为剧本，每组表演病例讨论 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

Medical Record of TCM Inspection, 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 cough 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 tongue, 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 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 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, 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 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 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 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 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 suffered from moving pain in the four extremities for twenty years, but no joints pain later years; diagnosis of jiuzheng could 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 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 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 result 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 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 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, 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 confirmed as no mental trouble. Systematic observation of the tongue, and pulse, and syndrome, the main disea~d 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 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 failure II atrial fibrilation

中医病案英语书写格式 TCM RECORDING

主诉、现病史、四诊

舌像与脉象

辩证分析 = 鉴别诊断

中医病机 = 病理机制

病史小结 = 本人建议

中医诊断 = Initial Impression of TCM

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建议 国庆后交 以电子版交给组长 各组长交给高秀飞 参与第一，撰写质量第二 《中医鉴别诊断学》06届某博士 著 《鉴别诊断中医英语》 吴 健 著

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