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Abstract: A 45-year-old middle-aged female patient with cough for six months, dyspnea for three months, and fever for two months presented to our hospital with a preliminary diagnosis of interstitial pneumonia by examining the lung CT and finding interstitial changes in both lungs. After the patient was given standardized medication, the cough and dyspnea symptoms were relieved and the disease was effectively controlled, but because the disease is a lifelong disease, continuous medication is required.
Basic information】Female, 45 years old
Type of disease】Interstitial pneumonia
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】April 2022
Treatment plan】Intravenous injection (sodium methylprednisolone succinate for injection) + oral medication (methylprednisolone tablets, omeprazole enteric capsules, calcium gluconate oral solution, compound sulfamethoxazole tablets, prednisone acetate tablets)
[Treatment period] Hospitalization for 10 days, outpatient review after 1 month
Treatment effect】The patient’s condition was controlled and the cough and dyspnea symptoms were relieved
I. Initial consultation
The patient developed cough and white sputum with no obvious cause six months ago, without symptoms such as hemoptysis, chest pain and dyspnea after activity, which was not a concern to the patient. 3 months ago, he developed dyspnea, decreased activity endurance and shortness of breath when going up a flight of stairs. He was admitted to our department because of the need for further investigation of the cause of interstitial pneumonia. The patient had pestle finger, mechanic’s hand, Gottron’s sign, Raynaud’s phenomenon, loss of skin pigmentation in the metacarpophalangeal joints and proximal interphalangeal joints of both hands, muscle aches and pains in the extremities, and sleep and diet, and a weight loss of about 7.5 kg in the past 2 months.
II. Treatment history
According to the examination results and physical examination, the patient was given intravenous injection of sodium methylprednisolone succinate for injection, and after 8 days of standard treatment, the treatment was changed to oral methylprednisolone tablets. At the same time, the patient was given omeprazole enteric capsules to protect the gastric mucosa, calcium gluconate oral solution to prevent calcium deficiency, and compound sulfamethoxazole tablets to prevent viral pneumonia.
III. Treatment effect
According to the comprehensive results of the patient’s symptoms, signs, imaging and related examinations, the diagnosis was quickly confirmed and standardized treatment was given. After 10 days of hospitalization, the patient’s fever and dyspnea symptoms were significantly relieved without other complications and was discharged. The patient’s lung CT was reexamined half a month later and the inflammation was found to have been absorbed. However, since it is a lifelong disease and cannot be cured, oral prednisone acetate tablets were required to control the disease progression. The patient was reexamined 1 month later in the outpatient clinic and his condition was basically stable without recurrence.
IV. Notes
We are glad that the patient is in remission, but after discharge, we need to advise the patient to pay attention to regular lung CT examinations to assess lung function. Pay attention to proper exercise in general to increase immunity and prevent colds. This disease can be combined with pulmonary embolism, so you need to pay attention to your symptoms, such as the sudden appearance of dyspnea, chest pain and other symptoms, to improve the coagulation six, double lower extremity venous ultrasound and other tests in a timely manner.
V. Personal insight
Interstitial pneumonia is a very complex disease with many causes and a variety of symptoms, which can be mild or severe. Some patients may have renal insufficiency or hepatic insufficiency as the first symptom, some patients may have myocardial damage as the main symptom, and some patients may have lymph node enlargement, which is atypical and easy to miss and misdiagnose. Therefore, if you encounter lung symptoms that cannot be explained by one disease in clinical practice, pay attention to be alert to interstitial pneumonia.