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Abstract: The patient in this case is a lady who has suffered from SLE for 8 years, and had previously been seen at a local hospital, and changed her own medication after her condition improved. Half a month ago, she suddenly had an elevated temperature and joint pain with cough and sputum, and her discomfort improved after she was seen at a local hospital, but she still had symptoms such as cough and sputum, and came to our hospital, where she was given medication for 7 days and improved, and continued She was given medication for 7 days and improved, and continues to be followed up in the outpatient clinic.
Basic information】Female, 65 years old
Disease Type】Lupus erythematosus
Hospital】The First Hospital of China Medical University
Date of consultation】March 2016
Treatment plan】Medication (Ambroxol hydrochloride sodium chloride, naproxen sodium for injection, cefminoxime sodium for injection, lanosterol for injection, metronidazole sodium chloride injection, prednisone acetate tablets, hydroxychloroquine sulfate tablets, white peony total glycoside capsule, alfacalcidol soft capsule)
[Treatment period] Hospitalization for 7 days, continued medication after discharge
Treatment effect】The condition improved and the discomfort symptoms basically disappeared
I. Initial consultation
The patient, a 65-year-old female, reported that she had fever with pain in both fingers and knee joints for no apparent reason 8 years ago, and was diagnosed with systemic lupus erythematosus at a local hospital. However, half a month ago, the patient measured his body temperature at 37.5℃, accompanied by coughing and coughing white mucous sputum, so he went to the local hospital for follow-up, and the doctor prescribed prednisone acetate tablets, hydroxychloroquine sulfate tablets, white peony total glucoside capsules, alfacalcitol soft capsules for oral administration, and after treatment, his body temperature returned to normal, and his joint pain was reduced, but he still had coughing and coughing sputum. The outpatient physical examination and laboratory tests showed that the respiratory sounds were coarse, indicating the presence of respiratory system diseases, as well as hematological involvement, positive anti-nuclear antibody and positive anti-ds-DNA, etc. The preliminary diagnosis was systemic lupus erythematosus, and the patient was admitted to the hospital.
II. Treatment history
According to the patient’s condition, the patient was given secondary care and further improved blood biochemistry and other related auxiliary examinations, including chest CT suggesting a few foci of fibrosis in both lungs, bronchiectasis and splenomegaly, which could confirm the diagnosis of having bronchiectasis. After communicating with the patient and his family, it was decided to take pharmacological treatment. It included sodium aminophenazone hydrochloride to promote sputum excretion, sodium naproxen for injection, which acted as an antipyretic and analgesic, and the addition of cefminoxime sodium for injection as an anti-inflammatory and anti-infective treatment. The patient’s temperature, pain intensity, cough and sputum were continuously monitored. On the fourth day of hospitalization, the patient developed toothache, and after consultation and treatment by the stomatology department, injectable lampetin was added to improve circulation, and metronidazole sodium chloride injection was added to anti-infective treatment.
III. Treatment effect
On the fourth day of hospitalization, the patient’s joint pain was reduced compared with that before admission and basically disappeared, and he was eating and resting normally. After 7 days of hospitalization, the patient’s joint pain basically disappeared, his body temperature was normal, and his cough and sputum disappeared. The results of the electrocardiogram were normal; the anti-nuclear antibody and anti-SSA antibody were positive, no focal fibers were found in the lung CT, and no obvious dry rales were detected on physical examination.
IV. Notes
The patient’s condition improved, his cough and sputum disappeared, and his joint pain was much relieved, so I was very happy to see his smiling face. At the same time, I reminded the patient to continue to take prednisone acetate tablets, hydroxychloroquine sulfate tablets, alphaprotein capsules and alfa osteoporosis soft capsules after discharge from the hospital, and that he should be re-examined in 2 weeks; and that he should pay attention to rest during the medication period to avoid getting cold and overexertion, so as not to affect the effect of medication; pay attention to sun protection when going out, wear a hat, sunscreen and sunblock, and avoid direct sunlight as much as possible; finally, because SLE requires continuous treatment, he should be discharged from the hospital. Lupus erythematosus requires continuous treatment, so it is not recommended to stop or change medication by oneself to avoid recurrence of the disease and aggravation of the treatment difficulty.
V. Personal insight
Since there is no special medicine for SLE, the most important point for patients diagnosed with the disease is early diagnosis and early treatment, and to follow the medical prescriptions for medication, so as to effectively control the disease and reduce the damage to their organs or other tissues. It did not lead to further aggravation of her condition.