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Abstract: The patient, Ms. Qi, was 48 years old. She had a history of sinusitis and allergic rhinitis, which improved after medical treatment, but recently she had recurrent symptoms such as runny nose and sneezing, and sought medical attention for fear of recurrent disease. After the imaging examination, it was clear that the nasal mucosa was edematous with a large amount of mucous secretion, so she was prescribed cromolyn methenamine nasal spray, cefothiamidine for injection, and aminoglutethimide hydrochloride oral solution for treatment, and her symptoms were gradually relieved.
Basic information】Female, 48 years old
Disease Type】Sinusitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】January 2022
Treatment plan】Oral medication (cetirizine hydrochloride tablets, cefixime capsules, aminoglutethimide oral solution) + topical medication (cromoglutethimide nasal spray)
Treatment Period】Take the standard medication for 1 week, follow up the discomfort
Treatment effect】The symptoms of discomfort gradually disappeared and the condition improved.
I. Initial consultation
When I first saw the patient, he wore a mask on his face and kept sneezing, running nose and tears, and his mental state was good. The patient told me that he had sinusitis and allergic rhinitis in the past, and that the discomfort was significantly aggravated especially in the spring flowering season. After the patient underwent nasal imaging, the results suggested bilateral nasal mucosal edema, visible mucous secretions, rightward deviation of the middle part of the nasal septum, difficulty in entering the right nasal cavity for microscopy, and inability to enter the nasopharynx from the right nasal cavity. White purulent secretions were seen in the nasopharynx, and the mucosa around the pharyngeal opening of the left eustachian tube was smooth, while the right pharyngeal opening could not be detected; the amber color of the bilateral tympanic membranes changed, and combined with the patient’s self-reported medical history, a clear diagnosis of sinusitis could be made.
II. Treatment history
In order to further clarify the severity of the patient’s condition, the patient actively cooperated to improve urinalysis, liver function test and blood glucose, etc. No abnormalities were found, and oral medication was considered for treatment. After obtaining the patient’s consent, I prescribed cetirizine hydrochloride tablets for anti-allergic treatment, supplemented with cefixime capsules for anti-inflammatory treatment to eliminate the symptoms of nasal mucosal edema. Since the patient’s nasal secretions were heavy and viscous in texture, an oral solution of aminoglutethimide hydrochloride was prescribed to promote the drainage of mucosal secretions, and a topical spray of cromolyn methenamine nasal spray was used to relieve allergic symptoms such as sneezing.
III. Treatment effect
After 3 days of drug treatment, the patient was informed by telephone call-back that the symptoms of runny nose and sneezing were relieved and the nasal secretion was significantly reduced. After 1 week of standardized drug treatment, the patient returned to the hospital for a follow-up examination and saw that the nasal secretions had disappeared significantly and the patient reported that the runny nose, sneezing and other uncomfortable symptoms had disappeared significantly. The patient was told to seek medical attention at any time if sneezing, runny nose and lacrimation appeared again.
IV. Precautions
I was happy to see that the patient’s symptoms disappeared and his condition was relieved after oral medication, but I advised the patient to pay attention to the following matters.
1, daily attention should be paid to avoid contact with pollen, animal hair and other allergenic substances, so as not to induce recurrence of the disease.
2, it is recommended to wear a mask when going out, especially in spring and summer, and should avoid going to crowded areas, so as to avoid the lack of air circulation resulting in more allergic substances in the air.
3, usually should pay attention to increase the intake of vegetables, fruits and other food, but also moderately increase the intake of high protein food, moderately increase the amount of exercise, so as to improve personal physical quality, improve the body’s ability to resist disease.
V. Personal insight
In this case, because the patient was clear about the existence of recurring diseases, she sought medical treatment promptly after the recurrence of previous diseases and treated the disease at the early stage of its onset, so that the symptoms could be better controlled by oral medication alone and could be cured in a short period of time. However, some people delay seeking medical attention after the onset of symptoms due to a fluke mentality, resulting in more severe symptoms, which may prolong the course of the disease or make treatment more difficult and affect the prognosis.