中医英语病案写作一
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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 (-).
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.
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 angBaidu Nhomakorabeae 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.
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
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.
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 angBaidu Nhomakorabeae 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.
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
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.