? Integrating ten methods of syndrome differentiation and treatment into Chinese medical records

Syndrome differentiation and treatment is the essence and law of traditional Chinese medicine, and it is the criterion and core of therapeutics. It is embodied in examining the cause, distinguishing the cause, legislating according to evidence, formulating prescriptions according to law, adapting to the time, optimizing the way, decocting, psychological adjustment, diet care and other links, which is generally called "ten methods of syndrome differentiation and treatment". Each method directly affects the curative effect, and whether it can be accurately and completely implemented in each medical record is the key to successful diagnosis and treatment. This paper attempts to refine the "ten methods of syndrome differentiation and treatment" in the writing of modern Chinese medical records, so as to make reference for standardizing the literature files of syndrome differentiation and treatment and diagnosis and treatment of Chinese medicine.

The Origin of Ancient Medical Diagnostic Books in China

Diagnosis, that is, medical records. Diagnosis, diagnosis and treatment also; The medical record is also a medical record that records the diagnosis and treatment process and results. Chunyu Kun, a famous doctor in the Western Han Dynasty, initiated the Diagnostic Book. According to Records of the Historian Biography of Bian Que and Cang Gong, Chunyu Kun's Diagnosis Book not only preserved the medical theoretical documents before the Western Han Dynasty, but also recorded his successful experience and failure lessons in treating diseases on the spot, which was the earliest prototype of medical records in China.

With the development of medicine and academic progress, TCM medical records are more colorful and valuable, and become the carrier of academic experience and the model of combining theory with practice. Therefore, there is a saying that "a good medical record is a book" and "reading a case is not as good as reading a doctor".

Writing of modern Chinese medical records

The items include the patient's name (real name, telephone activity and other privacy are hidden when published), gender, age, occupation, hometown, address, telephone number, time of first visit and other items. Each has its own meaning, so it should be recorded for subsequent visits and the authenticity of historical materials.

The present situation includes chief complaint, main symptoms and onset, aggravation time, past history, information obtained from four clinics, modern medical technology test parameters, etc. The description should be true, concise, orderly and concise, and avoid using adjectives to provide a basis for dialectical analysis.

The medical history includes the name of the disease, the onset time, whether it was cured, life history, birth history, menstrual history and the last time. It is necessary to understand both the present situation and the past, and look at the problem historically, so as to be comprehensive, thorough and clear at a glance.

In the analysis and demonstration of symptoms and signs based on the theory of traditional Chinese medicine, the necessary modern scientific and technological examination parameters are for reference only, and exploring the cause is called "examining the symptoms and seeking the cause". It provides a basis for further "differentiation of causes and syndromes". Starting from the etiology of the disease, this paper analyzes, demonstrates and explores the internal connection mechanism between a series of symptoms and signs, that is, looking at the essence through the phenomenon, which is called "differentiation of causes and syndrome differentiation", so as to confirm the pathological mechanism and conclusion of the formation of "this syndrome", that is, the pathogenesis, to characterize what this syndrome belongs to and to provide the basis for further "evidence-based legislation". "Examining symptoms and seeking causes" and "Examining causes and differentiating syndromes" are the main contents of the analysis.

Syndrome is the conclusion of analysis, that is, pathogenesis. If the syndrome belongs to "spleen and stomach deficiency and cold syndrome".

According to the analysis of the "evidence" of the conclusion, the corresponding and appropriate treatment method is established by legislation, which is called "evidence-based legislation". If it belongs to "spleen and stomach deficiency and cold syndrome", the treatment method of "warming the middle energizer and strengthening the spleen" can be established, which provides a theoretical basis for further "selecting prescriptions according to law" and "guiding according to the situation".

Prescriptions and drugs are "selecting drugs according to law and dispatching dispensing". According to the treatment method established by syndrome type, choose the appropriate prescription, and weigh flexibly, add and subtract according to the specific situation of this person, this syndrome, this time and this place to make it completely suitable. If you follow one side, or add or subtract the other side, or tailor it according to the meaning of one side, or draw up your own side. Starting from the other line, according to the monarch, minister, assistant and envoy, the prescription should be issued and the dosage should be considered. Special treatment and usage should be explained in the footnote, that is, prescription.

Usage: Explain in detail the most suitable dosage form, preparation method, usage and dosage of the above prescription. Oral administration: frequency, before and after meals, warm, cold, frequent and sudden. External use: location and method. Be sure to have detailed doctor's advice.

Fang Yi, which means Fang Jie, is an interpretation of "syndrome differentiation and treatment". If the analysis is "dialectical", then the meaning of the prescription is "treatment". Syndrome differentiation and treatment are the two most important things in medical records that embody the organic combination of theory and practice, which highlights the clinical treatment level of a doctor's combination of theory and practice and directly affects the treatment results.

A prescription is an explanation of a prescription. First of all, according to the clear syndrome type and treatment method, the prescription and medicine are selected in an orderly way, and its rationality is clear, so as to achieve the unity of prescription and medicine. Starting from the known etiology, syndrome types, pathogenesis, treatment methods and prescriptions, in the order of monarch, minister, assistant and envoy, this paper expounds the rationality of the compatible application of four groups of drugs, especially monarch and minister drugs, from the aspects of pharmaceutical theory, nature and taste, meridian tropism, function, indications and modern research results. Adjuvant drugs are aimed at concurrent diseases or anti-adjuvant drugs, and should be specially discussed when necessary; As a medicine, it has many functions, such as introducing classics, reporting classics, harmonizing and correcting taste. Then summarize the efficacy of the whole prescription after compatibility.

Nursing is the adjustment of mental psychology and the satisfaction of material needs. All related to aftercare, nursing, diet, taboos, rest, daily life, etc. In line with the principle of not violating the pathogenesis and being conducive to rehabilitation, patients or their families should be guided one by one in order to cooperate with medical treatment.

It is said that this is the crowning touch of the whole review of syndrome differentiation and treatment, which can be roughly divided into the first diagnosis, the second diagnosis and the general evaluation.

For the first-time medical records, according to the principles of treating the symptoms first, treating the symptoms first, and treating the symptoms later, the dialectical treatment scheme, symptoms, priorities, some special points to be explained, matters needing attention, prognosis and so on. Practice is the only criterion for testing truth. Prediction comes first, and the result comes later, so it should be tested in clinic.

Comment on the success or failure of the last treatment during the follow-up visit, adjust and determine the treatment opinions of this diagnosis and treatment, or the medicine and certificate are consistent, and then take the above; Or there is no better reason for the effect; Or the basis for changing course; Or add and subtract according to the formula.

The general review must look at the whole case and comment in turn. Generally speaking, in view of the successful experience and failure lessons of this case, seek truth from facts, briefly comment and draw a conclusion. It is necessary to highlight the diagnosis and treatment skills of syndrome differentiation, seek the root of the disease and grasp the main contradiction. It may also be caused by emotion or analogy. For example, vomiting, diarrhea and dehydration, I remember the lesson of the old lady in the neighborhood, which is caused by dehydration of acute gastroenteritis without treatment, and take it as a warning. If there are similarities and differences, list, compare and identify them, so as to broaden methods, increase knowledge and learn new things by reviewing old ones. For example, taking diarrhea as an example, compare, analyze and distinguish acute diarrhea, chronic diarrhea, diarrhea, bacillary dysentery, chronic dysentery, ulcerative colitis and other diseases. Make a long story short and express your views flexibly.

We should truly implement the "ten methods of syndrome differentiation and treatment"

Medical record is the best testimony of the level of syndrome differentiation and treatment. A clinical medical record is popular because of its high level of treatment and good notes, so there is a saying that "seeing a doctor is not like seeing a case" Because medical practitioners read medical theory books, mainly medical theory; A good medical record is often a vivid example of the close combination of medical theory and clinical practice, which has been expounded one by one and tested by practice, reflecting the whole process of syndrome differentiation and treatment. Therefore, we must attach importance to, improve and develop diagnostic books of traditional Chinese medicine, write modern medical records of traditional Chinese medicine and accumulate detailed information in order to sum up experience, discover laws and inherit innovation.

A complete and good medical record is simply a book. As a clinician, we should carefully practice the whole process of syndrome differentiation treatment and truly implement the ten methods of syndrome differentiation treatment in every link of the whole process.