中医病案英语书写格式RequirementsforAdmissionNote&CaseDiscussion中医双语教学BilingualTCM中医病案写作TCMAdmissionNoteContents(WesternM)Contents(TCM)Contents(TCM)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。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病因病机——虚证病史：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。鉴别诊断辨证论治妇科证候：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。ProcedureTCMPart：虚拟添加WesternMedicinePart中医病案书写格式中医病案书写格式中医病案书写格式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,scatteringbubblingsoundinth