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Abstract: Viral infections are common in clinical practice, the most common of which are respiratory viral infections, such as viral colds, which can lead to symptoms such as fever, stuffy and runny nose, and may progress to viral pneumonia if left untreated. In this case, the patient’s viral cold progressed to viral pneumonia because of self-medication and delayed treatment. After consultation and standardized antiviral, antipyretic and rehydration treatment, the patient’s condition improved, the discomfort disappeared, and the blood test and chest CT examination returned to normal.
Basic information】Male, 25 years old
Disease Type】Viral pneumonia
Hospital】Beijing Huairou District Hospital of Traditional Chinese Medicine
Date of consultation】May 9, 2022
Treatment plan】Antipyretic treatment (compound aminobarbital injection, aminophenol pseudo-malmefene tablets II/aminapenem tablets) + saline rehydration treatment + antiviral treatment (oseltamivir phosphate capsule, Jinhua Qingxian granules)
Treatment period】7 days of outpatient treatment, 1 month of follow-up
Treatment effect] Disappearance of discomfort symptoms, blood test and chest CT test are normal
I. Initial consultation
Three days ago, the patient started to have stuffy and runny nose, fever, malaise and other uncomfortable symptoms after getting wet, and her body temperature fluctuated from 37.5-38℃. On the third day, the body temperature rose to 39℃ at night, and the peripheral weakness with pain and coughing symptoms appeared at the same time. 22:10, the patient came to the emergency room, and the blood analysis indicated that the lymphocytes were mildly elevated, and the breath sounds were coarse on lung auscultation, and the patient was advised to check the chest CT, which indicated scattered inflammatory lesions in the lungs. Viral pneumonia.
II. Treatment
After a series of examination and physical examination, the patient’s body temperature had increased to 40℃, and he showed symptoms such as unstable walking and poor mental status. The patient was informed of the presence of hyperthermia and pneumonia and was recommended to be hospitalized, which the patient refused due to the high cost. Considering that a large proportion of current cold patients belong to influenza B, the patient was prescribed oseltamivir phosphate capsules and golden flower clearing pellets for antiviral treatment, while aminophenol pseudo-malmefene tablets II/aminobenzyme tablets were given to reduce fever and improve other symptoms. The patient was instructed to go home, drink plenty of fluids, take care of rest, follow up in 2 days, and revisit at any time if there was any aggravation of symptoms.
III. Treatment effect
After 3 days, the patient did not return to the hospital, and the patient complained that the symptoms of fever, malaise and peripheral pain had improved, and the temperature fluctuated around 38℃. One month later, the patient’s chest CT was repeated and no inflammatory manifestations were seen.
IV. Notes
We are glad that the patient has improved after treatment. The rehabilitation of viral cold and pneumonia is based on the use of antiviral and symptom control drugs on the one hand, and the patient’s own resistance on the other. Patients need to pay attention to rest, avoid straining and catching cold, and improve body resistance, otherwise it may prolong the recovery time of the disease and even lead to recurrence of the disease. Viral colds and pneumonia are mostly contagious and can be spread through the respiratory tract, so patients should pay attention to their own isolation, try to live alone at home in a well-ventilated room, avoid close contact with family members, share meals, and pay attention to hand hygiene.
V. Personal insight
We have seen too many cases of disease aggravation due to lack of timely treatment, some due to overconfidence in their own resistance, some due to lack of understanding of the disease, and some due to lack of timely consultation because of the cost. In this case, the patient was reluctant to consult the doctor because of the cost, which led to the aggravation of the disease and eventually doubled the cost of treatment. Maintaining good personal and environmental hygiene, balanced nutrition, moderate exercise, adequate rest, avoiding excessive fatigue, and maintaining a healthy lifestyle are the most economical and healthy measures to prevent diseases.