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Requirements for Admission Note&Case Discussion杨明山杨明山Requirements for Admission Not中医双语教学中医双语教学 Bilingual TCM中医英语第一属性是中医英语第一属性是“医医”中医双语教学 Bilingual TCM中医英语第一属性是中医病案写作中医病案写作 TCM Admission Note开展实践性中医英语开展实践性中医英语中医病案写作 TCM Admission Note开展实践本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。Contents(Western M)1.Title 2.Glossary 3.Prevalence4.Manifestation5.Laboratory6.Other Diagnostic Aids7.Diagnosis 8.Treatment(EBM)简单简单详细以便与详细以便与中医比对中医比对Contents(Western M)Title 简单详细本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。Contents(TCM)1.Title(中医病症中医病症)2.Chronology(年代年代-名医名医-名言名言-图图)3.Manifestation(偶字偶字)4.Pathogenesis(病机,经典引用病机,经典引用)5.TCM Diagnosis(少而精少而精)6.Inspection(舌象舌象-图谱图谱)7.Inquiry、A&O(可略可略)8.Palpation(脉证脉证-图谱图谱-形象化形象化)Contents(TCM)Title(中医病症)本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。Contents(TCM)9.TCM Therapy 注注:经典引用不是为了文学经典引用不是为了文学Principle(理理):授课可略;病案则详授课可略;病案则详Method(法法):少而精少而精Formula(方方):主方主方 验方验方Medicines(药药):主要药味主要药味-图谱图谱英文名与拉丁名英文名与拉丁名10.TCM(EBM):中医在循证医学评定中的地位中医在循证医学评定中的地位11.与现代科研关系与现代科研关系(有则谈之有则谈之,避免牵强附会避免牵强附会)Contents(TCM)TCM Therapy 注:经典本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。1.于于XX,24岁,女,未婚。岁,女,未婚。2.主诉:月经稀发主诉:月经稀发3年。年。3.现现病病史史:患患者者3年年前前因因自自认认为为肥肥胖胖,又又服服药药,又又节节食食,后后身身体体渐渐瘦瘦,饮饮食食少少,胃胃口口差差,而而后后月月经经周周期期错错后后,一一般般3至至5个个月月来来潮潮一一次次,行行经经34天天,经经色色淡淡,质质稀稀,无无块块,经经期期伴伴下下腹腹空空坠坠隐隐痛痛,平平素素头头晕晕眼眼花花,疲疲乏无力,心悸。面色黄无华乏无力,心悸。面色黄无华,舌淡,脉细。舌淡,脉细。病病 案案于XX,24岁,女,未婚。病 案本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。掌握掌握:月经后期的定义及辨证论治。熟悉:熟悉:月经后期的病因病机,诊断与鉴别诊断月经后期月经后期-目的要求目的要求掌握:月经后期的定义及辨证论治。熟悉:月经后期的病因病机,本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。1.1.定义:定义:2.2.月经周期延后月经周期延后7 7天以上,甚至天以上,甚至3 35 5月一行者。连续出现两个周期以上。月一行者。连续出现两个周期以上。3.3.本病首见于本病首见于金匮要略金匮要略 1.西医学的功能失调性子宫出血出现西医学的功能失调性子宫出血出现月经延后。月经延后。定义:本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。病因病机病因病机(肾虚(肾虚、血虚血虚、虚寒)虚寒)精血不足,冲任不充精血不足,冲任不充(虚(虚)(血寒(血寒、气滞)气滞)血行不畅,冲任受阻(实)血行不畅,冲任受阻(实)血海不能按时满盈血海不能按时满盈 病因病机(肾虚、血虚、虚寒)精血不足,冲任不充(虚)本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。病因病机肾虚血虚虚寒实寒气滞虚 实冲任不充冲任不充血行不畅血行不畅血寒病因病机肾虚虚 实冲任不充血行不畅血寒本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。病因病机虚证先天肾气不足,先天肾气不足,损伤肾气,肾虚精亏损伤肾气,肾虚精亏房劳多产房劳多产 血少,冲任不足血少,冲任不足体质素弱,营血不足体质素弱,营血不足 营血营血 不足不足 久病失血,产育过多久病失血,产育过多 冲任不充冲任不充脾气虚弱,化源不足脾气虚弱,化源不足 血海不能血海不能素体阳虚素体阳虚 阳虚内寒,脏腑失于温养,生阳虚内寒,脏腑失于温养,生 按时满盈按时满盈久病伤阳久病伤阳 化失期,气虚血少,冲任不足化失期,气虚血少,冲任不足 病因病机虚证本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。病因病机实证经期产后,外感寒邪经期产后,外感寒邪 血为寒凝血为寒凝 冲任欠通冲任欠通,血海,血海过服寒凉过服寒凉 运行涩滞运行涩滞 不能如期满溢不能如期满溢素多忧郁素多忧郁 血为气滞,运行不畅血为气滞,运行不畅 冲任受阻冲任受阻,血海,血海气机不宣气机不宣 不能如期满盈不能如期满盈病因病机实证本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。病史:病史:禀赋不足,或感寒饮冷、情志不遂史。禀赋不足,或感寒饮冷、情志不遂史。临床表现临床表现:“定义定义”,连续,连续2 2个周期以上。个周期以上。检查:检查:妇检妇检:无异常或子宫稍小。无异常或子宫稍小。辅助检查:辅助检查:BBTBBT、性激素、性激素、B B超。超。诊断诊断病史:禀赋不足,或感寒饮冷、情志不遂史。临床表现:“定本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。鉴别诊断1.早孕2.妊娠期出血病证鉴别诊断本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。辨证论治1.辨证要点辨证要点:根据月经的根据月经的量、色、质量、色、质及全身及全身 证候结合舌脉以辨虚、实、寒、热。证候结合舌脉以辨虚、实、寒、热。1.治疗原则治疗原则:以调整周期为主,:以调整周期为主,虚者补之,实者泄之。虚者补之,实者泄之。辨证论治辨证要点:根据月经的量、色、质及全身本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。妇科证候:妇科证候:周期延后,量少,色黯淡,质周期延后,量少,色黯淡,质清稀,或带下清稀。清稀,或带下清稀。全身证候:全身证候:肾虚证候。肾虚证候。舌舌 脉:脉:舌淡,苔薄白,脉沉细。舌淡,苔薄白,脉沉细。治治 法:法:补肾养血调经。补肾养血调经。方方 药:药:当归地黄饮当归地黄饮。熟地 山茱萸 山药 当归 杜仲 怀牛膝 甘草1 1、肾虚、肾虚 妇科证候:周期延后,量少,色黯淡,质清稀,或带下清稀。本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。2 2、血虚、血虚妇科证候:妇科证候:周期延后,量少,色淡,质清周期延后,量少,色淡,质清 稀,或小腹绵绵作痛。稀,或小腹绵绵作痛。全身证候;全身证候;血虚证候。血虚证候。舌舌 脉:脉:舌淡,脉细弱。舌淡,脉细弱。治治 法:法:补血益气调经。补血益气调经。方方 药:药:大补元煎加川芎。大补元煎加川芎。人参人参 炙甘草炙甘草 当归当归 熟地熟地 杞子杞子 杜仲杜仲 山茱萸山茱萸 山药山药2、血虚妇科证候:周期延后,量少,色淡,质清本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。3 3、血寒(、血寒(1 1)虚寒证)虚寒证妇科证候:妇科证候:月经延后,量少,色淡红,质清稀,月经延后,量少,色淡红,质清稀,小腹隐痛,喜暖喜按。小腹隐痛,喜暖喜按。全身证候:全身证候:虚寒证候。虚寒证候。舌舌 脉:脉:舌淡,苔白,脉沉迟或细弱。舌淡,苔白,脉沉迟或细弱。治治 法:法:扶阳祛寒调经。扶阳祛寒调经。方方 药:药:温经汤温经汤金匮要略金匮要略或艾附暖宫丸或艾附暖宫丸 温经汤:温经汤:当归当归 川芎川芎 白芍白芍 人参人参 丹皮丹皮 甘草甘草 生姜生姜 麦冬麦冬 法夏法夏 阿胶阿胶 桂枝桂枝 吴茱萸吴茱萸 3、血寒(1)虚寒证妇科证候:月经延后,量少本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。(2 2)实寒证实寒证妇科证候:妇科证候:月经周期延后,量少,色黯有块,月经周期延后,量少,色黯有块,小腹冷痛拒按,得热痛减。小腹冷痛拒按,得热痛减。全身证候:全身证候:实寒实寒证候。证候。舌舌 脉:脉:舌淡黯,苔薄白,脉沉紧。舌淡黯,苔薄白,脉沉紧。治治 法:法:温经散温经散寒调经。寒调经。方方 药:药:温经汤(温经汤(妇人大全良方妇人大全良方)。)。当归当归 川芎川芎 白芍白芍 人参人参 丹皮丹皮 甘草甘草 牛膝牛膝 肉桂肉桂 莪术莪术(2)实寒证妇科证候:月经周期延后,量少,色黯有块,小腹本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。4 4、气滞、气滞妇科证候:妇科证候:月经周期延后,量月经周期延后,量 少或正少或正 常,色黯红,或有血块,小腹胀痛。常,色黯红,或有血块,小腹胀痛。全身证候:全身证候:肝郁气滞证候。肝郁气滞证候。舌舌 脉:脉:舌正常或红,苔薄白或微黄,舌正常或红,苔薄白或微黄,脉弦或弦数。脉弦或弦数。治治 法:法:理气行滞调经理气行滞调经。方方 药:药:乌药汤。乌药汤。乌药乌药 香附香附 木香木香 当归当归 甘草甘草 4、气滞妇科证候:月经周期延后本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。1.1.转归预后转归预后2.2.结语结语3.概念概念月经周期延后月经周期延后7 7天以上,天以上,甚至甚至3 35 5月一行者。连续出现月一行者。连续出现两个周期以上。两个周期以上。4.辨证辨证虚、实。虚、实。5.治疗治疗调整周期为主。调整周期为主。转归预后本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。Procedure1.翻译病史陈述,改写中西医病案首页翻译病史陈述,改写中西医病案首页 2.翻译病例讨论,作出中西医版本,其中包括翻译病例讨论,作出中西医版本,其中包括中医的辩证论治中医的辩证论治3.有兴趣者,改写成中西医查房版本有兴趣者,改写成中西医查房版本 4.国庆后交作业国庆后交作业5.课程末排练表演课程末排练表演Procedure翻译病史陈述,改写中西医病案首页 本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。TCM Part:虚拟添加虚拟添加四诊包括四诊包括l问诊:十问歌基础,须与辩证有关者l舌像l脉象理法方药摄理法方药摄l病机l治疗原则l经典方剂l一最主要药味l加减药味l摄生TCM Part:虚拟添加四诊包括理法方药摄本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。Western Medicine Part1.改写原版,缩短至改写原版,缩短至2500字母以内字母以内2.保留阳性资料保留阳性资料 确诊依据确诊依据3.保留阴性资料保留阴性资料 除外诊断除外诊断4.其余删除其余删除5.格式按照教学格式按照教学Western Medicine Part改写原版,缩短至2本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。效果1.每组评选优秀写作一篇2.优秀者大幅度加分3.以优秀者为剧本,每组表演病例讨论4.邀请领导观摩,并拍录像效果每组评选优秀写作一篇本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。中医病案书写格式中医病案书写格式中医病案书写格式本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。中医病案书写格式中医病案书写格式中医病案书写格式本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。中医病案书写格式中医病案书写格式中医病案书写格式本文档所提供的信息仅供参考之用,不能作为科学依据,请勿模仿;如有不当之处,请联系网站或本人删除。Medical Record of TCMInspection,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 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.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 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 factors in fu-organs,upward disturbing of wind-phlegm2.Palpitation:hypoactivity of heart-yang,qi:deficiency blood stasisDiagnosis of WM:1.left-side hemiplegia cerebral thrombosis right-side internal carotid artery2.Rheumatic cardiac valvular disease,mitral stenosis and insufficiency heart failure II atrial fibrilation Medical Record of TCM中医病案英语书写格式中医病案英语书写格式 TCM RECORDING中医病案英语书写格式 TCM 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