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Abstract: A 25-year-old young girl, who developed cough and yellow sputum 4 days ago after exposure to cold, showed recurrent cough and shortness of breath in the past 2 days, which was aggravated by activity, and was seen in our hospital.
Basic information】Female, 25 years old
Disease Type】Acute bronchitis
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】April 2021
Treatment plan】Medication (Levofloxacin hydrochloride tablets, Ambroxol hydrochloride oral solution, Doxorubicin tablets)
Treatment period】7 days of outpatient treatment
Treatment effect] Symptoms improved and the disease was controlled
I. Initial consultation
The patient is a 25-year-old girl who felt nasal congestion, runny nose and cough 4 days ago, and her condition gradually worsened after self-medication. The patient had shortness of breath and was initially worried that she had asthma, so she came to our outpatient clinic for consultation. On examination: body temperature: 36.5℃, blood pressure: 120/65mmHg, clear consciousness, no cyanosis in the mouth and lips, trachea in the middle, normal thorax, no widening of rib space, thickened breath sounds in both lungs, scattered sputum sounds can be heard in both lungs, rales decreased after coughing; patient’s heart rhythm is uniform, no murmur; liver and spleen are not palpable enlarged. The initial diagnosis was acute bronchitis. Outpatient refinement of pulmonary CT showed basically normal results; ECG was normal; blood routine suggested elevated white blood cell count and neutrophil count; the patient was in good health in the past, with no history of smoking and no history of allergy.
(Pulmonary CT)
II. Treatment history
The patient with acute bronchitis was first treated for the cause. According to the patient’s symptoms, such as coughing and coughing yellow sputum, the routine blood results showed elevated leukocytes and neutrophils, the possibility of bacterial infection was considered, and antibiotic treatment was given, and oral levofloxacin hydrochloride tablets were administered. Secondly, symptomatic treatment was given. Since the patient had cough with sputum and it was not easy to cough it out, amiloride hydrochloride oral solution was used to dissolve the sputum. The patient had shortness of breath after activity and sputum sounds in the lungs on examination, considering infection causing bronchospasm, and was given the asthma calming drug Doxorophylline Tablets orally. 5 days later, the patient’s symptoms were reduced and antibiotic treatment with Levofloxacin Hydrochloride Tablets was discontinued, and he could continue to take oral solution of Ambroxol Hydrochloride to stop coughing and dissolve sputum, drink more water to promote sputum excretion, and discontinue the use of Doxorophylline Tablets.
III. Treatment effect
After 3 days of antibiotic treatment, the yellow sputum was reduced; after symptomatic treatment with oral administration of Ambroxol hydrochloride solution and Doxorubicin tablets, the patient coughed up the yellow sputum more easily, so the shortness of breath improved significantly. After 7 days of outpatient treatment, the patient’s symptoms were significantly reduced, so it was recommended to stop the medicine completely for observation, and the patient was advised to make sure to take more rest, drink more water, replenish enough calories, and prevent straining and getting cold to prevent recurrence of symptoms.
IV. Notes
We are glad that the patient’s symptoms have improved and the disease has been controlled, but we still need to advise the patient to pay attention to good protection and avoid going to places with a lot of smoke and dust or inhaling second-hand smoke to avoid aggravating the cough and affecting the recovery of the disease. You should pay more attention to rest and avoid staying up late, straining or heavy physical work. Take a light, high-quality protein diet and avoid spicy, oily foods that may aggravate your cough. In addition, pay attention to actively participating in outdoor exercise and keeping your mood relaxed, which will help develop a good physique and increase your resistance.
V. Personal insight
Acute bronchitis is easy to diagnose, and clinical diagnosis and determination of the cause can be made based on medical history, symptoms, physical features, imaging manifestations, and infection-related tests. In this case, the pathogenic diagnosis can be made by combining relevant laboratory tests during the treatment of the patient, and the lower respiratory secretions can be sent for viruses, Mycoplasma pneumoniae and bacteria, which can be used to guide the clinical selection of correct therapeutic drugs. For acute bronchitis that is not an infection factor do not use antibiotics indiscriminately to prevent drug resistance and secondary dysbiosis.