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Abstract: The patient came to the outpatient clinic with fever for 2 days, aggravated with cough for 7 days, and was diagnosed with mycoplasma pneumonia, and the symptoms were effectively controlled with aggressive drug therapy. Mycoplasma pneumonia usually presents with symptoms such as fever and cough, and many patients have fever for 2-3 days and then the fever resolves on its own. The disease is self-limiting, and most patients with mild disease can recover on their own without treatment. Mild pneumonia can also be treated early with antibiotics to reduce symptoms and shorten the course of the disease.
Basic information】Female, 36 years old
Disease Type】Mycoplasma pneumonia
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】April 2016
Treatment plan】Medication (moxifloxacin hydrochloride sodium chloride injection + moxifloxacin hydrochloride tablets)
Treatment period】7 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect] Symptoms were controlled and relieved
I. Initial consultation
The patient entered the consultation room with a very heavy and incessant cough. The patient reported that he was particularly tired at work in recent days, often working overtime and staying up late. 2 days ago, he developed fever due to cold, with a maximum temperature of 39℃, mostly in the afternoon, accompanied by chills and muscle aches, without nausea and vomiting. The day before admission, a cough appeared, which was relatively heavy and affected rest. No sputum, oral cefaclor capsules for 2 days cough did not improve, cough aggravated, but the patient’s fever reduced, so he came to our hospital, in the outpatient clinic to take CT showed: bilateral lung patchy exudate. He was initially diagnosed as mycoplasma pneumonia and admitted to the department.
II. Treatment history
After admission, we examined: acute face, no rales were heard in both lungs, heart and abdomen (-), no swelling in both lower limbs. The routine blood tests were basically normal. Combined with the imaging examination, the patient was considered to have atypical pathogen pneumonia. Later, the relevant tests were completed: antibodies to viruses and mycoplasma, etc. The patient was given moxifloxacin hydrochloride sodium chloride injection intravenously, and the family and nurse were instructed to monitor the patient’s body temperature and to take moxifloxacin hydrochloride tablets orally while the patient was taking the medication.
III. Treatment effect
After drug treatment, the patient’s symptoms of fever and cough were gradually relieved, and there were no other uncomfortable symptoms during the medication period, so the patient was discharged from the hospital at 7 days, and was advised to continue to take oral medication after discharge, and was recommended to come to the hospital for a lung CT review in 1 month. Cough medicine.
IV. Precautions
After active medication, the patient’s symptoms have effectively improved, which is very gratifying. However, it is still recommended that patients should pay attention to their daily diet even though their condition has been cured. In addition to quitting smoking and drinking, they should also pay attention to a light diet and not eat too spicy and greasy food to avoid aggravating their cough symptoms. Exercise in daily life can be done appropriately. In winter and spring, when the climate changes rapidly, attention should be paid to opening windows and keeping indoor air circulation to avoid recurrence of symptoms.
V. Personal insight
For most patients with mild to moderate infections, oral treatment should be given by selecting antimicrobial drugs that are well absorbed orally, and intravenous administration is not necessary. For patients with mycoplasma pneumonia who do not show significant improvement even after 72 hours of macrolide antibiotic treatment, the possibility of infection by macrolide resistant strains should be considered and it is recommended to switch to quinolones, such as levofloxacin hydrochloride tablets. In addition, patients in this article are mainly induced by staying up late and working overtime with mycoplasma pneumonia, so it is recommended that you should pay attention to rest and combine work and rest to avoid jeopardizing your health and triggering mycoplasma pneumonia or other discomforts.