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Abstract: The patient in this case is a 71-year-old aunt who came to our hospital due to symptoms such as fever, cough, coughing white sputum and shortness of breath 5 days ago. She reported a past smoking history of more than 30 years and quit smoking for two years, and was diagnosed with chronic bronchitis after examination, so she was given anti-inflammatory, wheezing and sputum-reducing drugs, and after 10 days of standardized treatment, her symptoms improved and her condition gradually recovered, and all indicators were improving.
Basic information】Female, 71 years old
Disease Type】Chronic bronchitis
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】March 2022
Treatment plan】Medication (azithromycin for injection, azithromycin tablets, doxorubicin tablets)
Treatment period】Outpatient treatment for 10 days, regular outpatient follow up
Treatment effect】The disease has been controlled, and all indicators are improving
I. Initial consultation
Auntie is a 71-year-old aunt who came to the clinic with recurrent cough and sputum for 11 years, with shortness of breath and palpitations for 3 years, and aggravated with wheezing for 5 days. She reported that she had fever, cough and pus sputum after catching a cold 11 years ago, and since then she often coughs and coughs white foamy sputum, sometimes pus sputum, in winter and spring, with repeated aggravation. 3 years ago, she often felt palpitations after working or exercising, and 5 days ago she had fever, cough aggravation, white sputum and shortness of breath after catching a cold, so she came to the clinic for consultation.
Physical examination: body temperature: 38.4℃, pulse: 108 beats/min, respiration: 24 breaths/min, blood pressure: 102/79 mmHg, heart rate 108 beats/min. Auntie showed a chronic appearance, sitting breathing, no obvious cyanosis of lips and skin, no jugular venous anger, no obvious depression of sternum and supraclavicular fossa during inspiration, no barrel chest, reduced respiratory kinetics, scattered dry and wet rales in both lungs, uniform cardiac rhythm, narrowed turbinate border, no abdominal bulge, no palpable enlargement of liver and spleen, no depressed edema in both lower limbs. He had a history of smoking for 30 years, and quit smoking 2 years ago after a medical examination revealed chronic bronchitis.
II. Treatment history
Auntie was instructed to improve the lung CT, the results indicated that the texture of both lungs was slightly enhanced; the lung function was checked, which showed that the small airway function was reduced (as shown in the figure); the blood routine was checked experimentally, and the white blood cell and neutrophil counts were elevated; the mycoplasma test was perfected, and the antibody was 1:160, so Auntie was considered to have chronic bronchitis caused by mycoplasma infection. Administered injectable azithromycin static point, after 3 days changed to oral azithromycin tablets to control inflammation, with oral doxorubicin tablets to improve the obstructed breathing.
III. Treatment effect
After the first 3 days of intravenous infusion treatment, the shortness of breath was slightly reduced and the fever symptoms were controlled. Subsequently, the intravenous infusion was stopped and oral medication was given to continue the treatment for 7 days, the aunt’s cough symptoms were significantly improved, the dyspnea symptoms were improved, the coughing sputum was reduced, the palpitation symptoms were controlled, and the body temperature and heart rate returned to normal.
IV. Notes
We are glad that she was treated effectively, but we still need to pay attention to avoid going to places with more smoke and dust, avoid smoking again or inhaling second-hand smoke, and pay attention to keeping the airway warm when the weather turns cool, and wear a mask when going out. In daily life, pay attention to adjusting the diet structure, it is recommended to focus on high-protein foods, increase nutrition, and increase the intake of vegetables and fruits. In addition, avoid strenuous exercise and heavy physical work, suitable physical exercise can enhance physical fitness and increase heart and lung function, such as brisk walking, swimming, taijiquan, abdominal breathing, chest expansion exercises, etc.
V. Personal insight
Auntie has a history of smoking in the past, and although she has quit smoking, she has quit for a short period of time. If she does not pay attention to recurrent attacks, she is likely to develop chronic obstructive pulmonary disease or even chronic pulmonary heart disease. In life, chronic cough is often easily overlooked. Many patients think it is normal to have cough symptoms from smoking and often tend to ignore the symptoms and only come to the clinic when they have obvious breathing difficulties, palpitations or even swelling of the lower limbs, when the disease has reached a serious stage. This is why it is important to raise awareness of the need for early diagnosis and early treatment.