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Abstract: This is a case of a 25-year-old college student who came to the clinic with a fever for two days. The patient presented with symptoms such as throat, runny nose, generalized muscle pain, malaise, and cough. Based on the symptoms and blood count, the diagnosis was “common cold”, which is caused by viral infection and can also be called viral cold. After 3 days of medication, the patient was cured.
Basic information】Male, 25 years old
Type of disease】Viral cold
Hospital】The Second Hospital of Harbin Medical University
Time of consultation】June 2016
Treatment plan】Medication (compound acetaminophen tablets, Su Huang cough capsules)
Treatment Period】3 days of outpatient treatment
Effectiveness】The disease was cured
I. Initial consultation
The patient, a college student, had symptoms of sore throat and fever with a maximum temperature of 38.5℃ 2 days ago due to cold, accompanied by sneezing, clear watery nose, hoarseness and cough, but no yellow sputum, headache, nausea and vomiting. Before seeking medical attention, the patient took oral amoxicillin capsules on his own for 2 days, and now his diarrhea symptoms have decreased, he still has hoarseness and low fever, so he came to the outpatient clinic. Physical examination: red and swollen pharynx, no enlargement of tonsils, no dry and wet rales in both lungs, heart rhythm, normal abdomen. Blood count: lymphocytes and monocytes were elevated, and white blood cells were normal. The patient was in good health and had no history of smoking or alcohol consumption. According to the patient’s symptoms and related examination, he was considered to have “viral cold”.
II. Treatment history
Firstly, the patient was advised to take general treatment, i.e. to pay attention to daily rest, avoid staying up late and straining, and to regulate diet. Secondly, medication is administered mainly to reduce symptoms and prevent complications. Patients with cold with fever, headache, muscle pain, sore throat can take oral antipyretic and analgesic drugs, body temperature over 38.5℃, can take oral compound acetaminophen tablets, body temperature below 38℃ to physical cooling. Or tell the patient can take oral cotrimoxazole capsules, if cotrimoxazole capsules, can be used without antipyretic drugs. Patients with slightly heavy cough affecting rest at night are given Su Huang cough capsules for cough suppression and advised to stop taking antibiotics.
III. Treatment effect
The patient’s fever, headache, muscle aches, cough and sore throat symptoms were significantly reduced after taking oral antipyretic and analgesic drugs, and the body temperature is now below 38°C. The patient was advised to drink more warm water, take more rest and avoid staying up late. 2 days later the fever, nasal congestion and runny nose have disappeared. In addition, the patient was advised to have more ventilation indoors to prevent infection or cross-infection. Outdoor activities can be performed appropriately. After the abdominal discomfort improved, a high-quality protein diet was recommended. Under reasonable dietary regulation the patient’s strength gradually increased and the symptoms of weakness improved significantly.
IV. Precautions
I am glad that after treatment, the patient’s disease was cured, and at the same time, it is suggested that the patient needs to pay attention to the following points when he has a cold.
1, because the cold is mostly a viral infection, patients should pay attention to rest after the disease is cured, drink more water, and avoid staying up late and straining.
2, diet, pay attention to nutrition, eat more vegetables and fruits, high-quality protein, diet should be easy to digest, do not eat too spicy and greasy food, so as not to aggravate the gastrointestinal tract reaction.
3, enhance the body’s immunity and cold resistance, so more outdoor exercise, such as jogging, swimming, playing ball and other activities, especially in winter and spring.
V. Personal insight
From the patient’s treatment, basically no drugs are used, but general treatment is the main focus. Colds are very common clinically, and can be divided into common cold and influenza, there is a difference between the two pathogens, common cold 70%-80% is caused by rhinovirus, coronavirus, adenovirus and parainfluenza virus, etc., a small number of bacteria or mycoplasma infection; and influenza is caused by influenza A, B, C virus, the vast majority of influenza A and B virus, therefore, clinically Viral colds are very common. When a viral cold appears, treatment is symptomatic and does not require antibiotics. However, if there is a yellow pus nasal discharge, accompanied by fever outside and an increase in white blood cells and neutrophil percentage, antibiotics can be applied under the guidance of a doctor.