病 案
TCM Case:Consumptive Disease
Mr.Zhang，12 years old.
Main Complaint:Headache，tinnitus，weakness and palpitations relapse for nearly a month.
Medical History:The patient gradually suffered from increasing symptoms of headache，blurry vision，occasional tinnitus，fatigue，weakness，palpitations and flustered complexion after exertion，lack of concentration and memory loss which obviously affected his grades.Blood test showed Hb level at 74g/L and the patient was diagnosed with iron deficiency anemia1).He was immediately administered blood nourishing Chinese medications and vitamin C.Blood tests done every two weeks confirmed the gradual increase of the Hb volume.He maintained this therapy for half a year and his Hb peaked at 118g/L while symptoms relieved significantly.At that time，the patient stopped his medication.Last month，the patient had a relapse of his previous symptoms and went for a consultation.Blood test indicated Hb level of 75g/L.He was asked to take iron supplements in oral liquid form for a month.However，the blood test remained at Hb 78g/L at the next follow-up visit.Therefore，he decided to take Chinese medicine.The patient had no history of contagious diseases such as hepatitis or tuberculosis and no history of blood diseases.
Presenting Symptoms:Headache，blurry vision，tinnitus，weakness，palpitations,vexation2),poor sleep,poor appetite,abdominal distension and loose stool.The patient was thin and tall with no vitality in the eyes，a pale and lusterless3) complexion and lips，pale eyelids and nails，edema of the eyelid with a dark bluish color，a thin，pale and small tongue with a white and greasy coating and thin pulse.
Other Medical Test Results:
Blood routine test:WBC 8.6×109/L，RBC 5.1×1012/L，Hb，PLT 84×109/L,HCT 30.3%，MCV 57.6fl，MCHC 242.2 g/L，MCH 14.3pg.A narrow aspiration test confirmed the proliferative anemia with possible iron deficiency anemia.There were no abnormal findings in the stool and urine tests.
Diagnosis
TCM Dianosis:Deficiency and consumption syndrome due to spleen qi and heart blood deficiency with kidney essence depletion
Western Medicine Diagnosis:Iron deficiency anemia(https://www.daowen.com)
Treatment
Principles:
·Tonify the spleen qi and supplement the heart blood
·Strengthen the kidney and nourish the essence
Formula：Modified Guī Pí Tāng（Spleen-Restoring Decoction）from the Formulas to Aid the Living（Jì Shēng Fāng，济生方）
注释：
1）iron deficiency anemia 缺铁性贫血
2）vexation 苦恼，恼怒，令人烦恼的事
3）lusterless 没有光泽的