Presentation on theme: "中医病案英语书写格式 TCM RECORDING. Medical Record of TCM Inspection, Auscultation and olfaction, Pulse-feeling and Palpation ： clear consciousness and cooperation,"— Presentation transcript:
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
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