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Abstract: The patient came to our hospital with worsening cough and sputum symptoms and fever. I made a preliminary diagnosis of bronchopneumonia through physical examination and routine blood results combined with the patient’s clinical presentation. Since his symptoms were not serious and did not require hospitalization, he was treated with cough and expectoration, anti-inflammatory drugs and physical hypothermia. After 2 weeks of the above treatment, the patient’s condition had completely improved when he came to our hospital for a follow-up examination 1 month later.
Basic information】Male, 70 years old
Disease Type】Bronchopneumonia
Hospital】The First Hospital of China Medical University
Consultation time】November 2019
Treatment plan】Medication (bromohexine hydrochloride tablets, acetylcysteine tablets, amoxicillin potassium clavulanate tablets, cefixime capsules)
[Treatment period] 1 day of outpatient treatment, 2 weeks of out-of-hospital treatment
Treatment effect] The condition recovered well, and all indicators improved.
I. Initial consultation
The patient, a 70-year-old male, reported coughing and sputum with dry throat and itchy throat 10 days ago, but he did not seek medical treatment because it was not serious. However, in the past 2 days, his symptoms worsened significantly and he developed a fever, so he went to our outpatient clinic. I learned from talking with the patient that he had been hospitalized several times for cough, sputum, and fever for only 1 year (the exact hospitalization is unknown), and had a past history of hypertension, type 2 diabetes, and cataracts. The patient was examined and found to have a temperature of 37.4°C, high blood pressure, a slightly congested pharynx, no tonsillar enlargement, coarse breath sounds in both lungs and audible wet rales, and a routine blood test that revealed an elevated neutrophil count and a decreased lymphocyte count. The preliminary diagnosis of bronchopneumonia was made through physical examination, routine blood results and clinical manifestations of the patient.
II. Treatment history
After diagnosing the patient’s disease, I told the patient that since his symptoms were not serious and he did not have chest pain and dyspnea, he did not need to be hospitalized and could be treated by taking cough expectorant and anti-inflammatory drugs with physical cooling. After the patient and his family relaxed, they agreed to the drug treatment plan, so the patient was given bromohexine hydrochloride tablets and acetylcysteine tablets to stop coughing and expectoration, and amoxicillin potassium clavulanate tablets and cefixime capsules for antiseptic and anti-inflammatory treatment. At the same time, the patient was instructed to go home and use wet towels to cool down the temperature, and then insist on taking medication for 2 weeks. During the period of taking medication for bronchopneumonia, the patient could take normal antihypertensive and hypoglycemic drugs, and be reviewed after 1 month to see if the condition had completely improved.
III. Treatment effect
The patient came to our hospital because of the aggravation of cough and sputum and fever. After taking the above-mentioned cough and expectorant and anti-inflammatory drugs orally, the patient reported that his condition had completely improved when he came to our hospital for follow-up one month later, and his cough, sputum and fever disappeared, and there was no recurrence during the period. I examined him and found that his body temperature and blood pressure were normal and there were no abnormalities in other areas. Routine blood tests revealed that all indicators were normal, and it was determined that the patient had completely recovered.
IV. Precautions
I was also pleased that the patient in this case had a mild condition and recovered with conservative treatment. At the same time, in order to help the patient recover better at home, I need the patient and his family to pay attention to the following matters.
1. Since the patient has coughing sputum, in order to help the patient cough up the sputum more easily, it is recommended to use a humidifier in the house to help keep the environment moist and indirectly increase the moistness of the respiratory tract to facilitate the sputum discharge. In addition, family members can also help patients pat their backs to promote coughing up sputum.
2, in terms of diet, patients need to pay attention to eating more vegetables and fruits such as spinach, tomatoes, watermelon, etc., drinking more water, and eating less greasy and spicy food, which can easily produce adverse stimulation to the respiratory tract and lead to aggravation of the disease.
3, patients must adhere to the medication treatment, avoid unauthorized discontinuation or reduction of drugs, so as not to reduce the effectiveness of drugs, weakening the therapeutic effect, resulting in the prolongation of the disease.
V. Personal insight
Bronchopneumonia is commonly caused by bacterial and viral infections, which can lead to symptoms such as fever, cough, coughing and even shortness of breath. As in this case, the patient’s performance is relatively mild and does not show serious symptoms such as shortness of breath, so it does not require hospitalization for treatment such as oxygen, and the prognosis is relatively good and can generally be cured. However, there are some patients who have developed more serious symptoms, such as respiratory failure and acute kidney injury, and need to be treated with respiratory support. Therefore, it is recommended that patients with bronchopneumonia should seek early medical treatment for early recovery.