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Abstract: The patient presented with a fever of up to 38.2°C for 3 days. He was given symptomatic treatment at the clinic, but his temperature was not effectively controlled, so he came to the clinic. After the consultation, the patient was given a chest CT and blood tests, and a lung infection (coronavirus infection) was initially suspected. Based on the patient’s medical history and examination, he was diagnosed with novel coronavirus pneumonia and was given medication.
Basic information】Male, 63 years old
Disease type】New coronavirus pneumonia
Hospital】The 988th Hospital of the PLA Joint Logistics and Security Forces
Date of consultation】January 2020
Treatment plan】Medication (moxifloxacin hydrochloride sodium chloride injection + abidor hydrochloride tablets + recombinant human interferon alpha 2b for injection + methylprednisolone sodium succinate for injection) + psychological counselling
Treatment period】24 days of inpatient treatment, 2 years of outpatient follow-up
Treatment effect】The disease has been controlled and all indexes are gradually normalized.
I. Initial consultation
The patient, 63 years old, was admitted to the clinic with fever for 3 days, and his body temperature reached 38.2°C. He was given symptomatic treatment at the clinic, but his body temperature was not effectively controlled, so he requested inpatient treatment. After consultation, the patient was examined: body temperature 37.8°C, pulse 140 beats/min, respiration 22 breaths/min. The patient had a history of hypertension, was stable on long-term oral medication, and had no history of other chronic underlying diseases. The blood tests showed: leukocytes 5.3×10^9/L, hemoglobin 139g/L, neutrophil ratio 72.9%; chest CT showed: inflammation of the upper lobe of the right lung and the lower lobe of the left lung (progressive stage), grinding glass nodules in the posterior segment of the upper lobe of the left lung, pericardial thickening, and a small amount of effusion on the right side.
II. Treatment history
The patient was given a combination of moxifloxacin hydrochloride sodium chloride injection for anti-infection, oral Abirater hydrochloride tablets, nebulized inhalation recombinant human interferon α2b for injection for antiviral, and injectable methylprednisolone sodium succinate to reduce the inflammatory response. The patient’s fear of the disease, confusion about the prognosis, psychological pressure, the need for isolation due to the special nature of the disease, the inability to contact with family members, mood swings, and timely psychological counseling was given to the patient.
III. Treatment effect
Through 24 days of anti-infection, anti-virus, reducing the inflammatory response of the body and psychological counseling, the reexamination of the new coronavirus pneumonia was negative for nucleic acid, and the chest CT suggested that the foci were significantly absorbed. The patient’s body temperature returned to normal, her spirit and diet were normal, and she was discharged with no obvious discomfort. Because of the new infectious disease of the disease, there are still many problems to be solved, so the patient was followed up for a long time, and so far there are no obvious unwell symptoms and the status is good. The patient was instructed to follow up for 2 years on an outpatient basis and to seek medical attention in a timely manner if there is any usual discomfort so as not to delay the disease.
IV. Notes
I was happy that the patient recovered from the treatment. Therefore, patients should try to keep the indoor air fresh, open windows frequently, and pay attention to the disinfection of objects at home; pay attention to protection when going out, wear masks, wash hands regularly, reduce the number of times of touching face, rubbing eyes, and holding food directly, and reduce the number of public gatherings; keep optimistic mood, ensure sufficient sleep, and have regular diet and rest. In general, we should also maintain an optimistic mood, ensure adequate sleep, regular diet and rest, and actively exercise.
V. Personal insight
The new coronavirus is highly infectious, but it can be effectively inactivated by chlorine disinfectant, 75% alcohol and ultraviolet light. Most of the prognosis is good, but a few elderly people and people with chronic underlying diseases are prone to serious illness. Therefore, do not be nervous and anxious, do self-protection, develop a “one-meter line” distance, and promptly seek medical attention when fever or respiratory symptoms appear. Even if you are unfortunate enough to be infected, don’t be pessimistic and disappointed, but be positive and overcome the disease. Usually, after treatment, the disease can be effectively controlled and cured as well as the patient.