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Abstract: The patient in this case is a 59-year-old woman who presented with moderate hemoptysis one hour before consultation. After examination of the lung CT and other tests, she was diagnosed with bronchopneumonia and was treated with medication in our hospital to control the infection, improve the discomfort and prevent further aggravation. After 8 days of in-hospital treatment, the patient’s discomfort basically disappeared and all indicators improved.
Basic information】Female, 59 years old
Disease Type】Bronchopneumonia
Hospital】The First Hospital of China Medical University
Date of consultation】September 2021
Treatment plan】Oral medication (amoxicillin capsule, aminoglutethimide oral solution) + intravenous injection (phentolamine mesylate injection)
Treatment period】Hospitalization for 8 days, long-term follow-up
Treatment effect】The condition was controlled, and the symptoms of hemoptysis, cough and sputum disappeared.
I. Initial consultation
The patient was a 59-year-old female with a history of hypertension for 5 years. 1 hour ago, she developed hemoptysis of bright red color, about 100 mL, accompanied by cough and mucus sputum, without other abnormal symptoms such as vomiting, fever and wheezing, and came to our hospital urgently. Physical examination showed no deformity of the thorax, no varicose veins in the chest wall, no local bulge or collapse, no pressure pain in the chest wall or sternum, normal respiratory motion bilaterally, normal fibrillation bilaterally, no pleural friction and subcutaneous twisting sensation, clear percussion sounds in both lungs, low breath sounds in both lungs, no dry and moist rales and pleural friction sounds were heard. Chest CT showed patchy cloudy dense foci around some bronchi in both lungs with unclear borders, and patchy fibrous foci in both lungs with unclear borders. The initial diagnosis was bronchopneumonia, combined with bronchodilation and hemoptysis, and the patient was admitted to our department for treatment.
II. Treatment history
After the patient was admitted to the hospital, the routine blood and liver and kidney function tests were further improved, indicating elevated white blood cell count and neutrophils, and sputum culture was performed, which clearly indicated bacterial infection. After communicating with the patient and his family, it was decided to achieve anti-infection and anti-inflammation through pharmacological treatment. According to the results of the drug sensitivity test, amoxicillin capsules were applied for anti-bacterial infection treatment to control the further development of bronchopneumonia as well as bronchial dilatation; amoxicillin hydrochloride oral solution was used to dilute sputum and promote sputum discharge; phentolamine mesylate injection was administered intravenously to play a hemostatic role. The patient’s vital signs such as oxygen saturation, blood pressure and heart rate were continuously monitored, as well as whether the hemoptysis stopped.
III. Treatment effect
After 8 days of treatment, the patient’s hemoptysis stopped and no symptoms such as anemia appeared; the coughing sputum basically disappeared, with occasional coughing; the re-examination of lung CT showed that some bronchial irregular thickening still existed in both lungs, and high-density foci of patches of cloudy flocculence with unclear boundaries were seen around them, but they were absorbed and reduced in scope compared with the previous CT film. This indicates that the treatment was effective and the bronchopneumonia was basically cured. However, regular follow-up examinations and CT examinations are still needed to monitor the lung condition.
IV. Precautions
The patient was very happy to be discharged after treatment and control of his condition, and I was also happy for the patient’s improvement. At the same time, I told the patient and his family that the most important point after discharge is to improve their resistance and prevent secondary infection because of the patient’s age. First of all, according to the weather conditions, you should add clothes in time, because the temperature difference between morning and evening is large, so do not be cool when the weather is hot during the day, and dry in time after sweating, and wear a jacket in the early morning and evening to prevent getting cold; secondly, indoor windows should be opened regularly to ensure air circulation; finally, cooking, sweeping the floor and other fumes, dusty household chores, as far as possible by family members to reduce the chances of patients inhaling irritating gases.
V. Personal insight
Bronchopneumonia occurs in people with low resistance and is mainly caused by bacterial, viral and other pathogenic infections. As in this older patient, when bronchopneumonia is diagnosed, the first step should be to control the inflammation and pathogenic infections, take symptomatic treatment according to the different clinical symptoms, and be careful to prevent complications of bronchodilatation, and after recovery, you also need to improve bad habits and actively improve your resistance to prevent recurrence. If headache, fever, cough, sputum, shortness of breath and other uncomfortable symptoms appear, you should seek medical attention promptly.