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Abstract: Pneumonia is one of the common diseases of the respiratory system and can develop at any age. The etiology of pneumonia is also broad and can include bacteria, fungi, viruses, atypical pathogens, etc. The symptoms are mainly fever, cough, sputum, chest tightness, chest pain, and even hemoptysis and other respiratory symptoms. This patient is a patient with pneumonia that appeared after a rain shower. After hospitalization, the patient’s symptoms improved significantly through anti-infection, cough and sputum treatment.
[Basic information] Male, 65 years old
Disease Type】Pneumonia
Hospital】Weihai Central Hospital
Date of consultation】April 2020
Treatment plan】Medication (piperacillin sodium tazobactam sodium for injection + pulmonary cough combination + budesonide suspension for inhalation + terbutaline sulfate nebulizer)
[Treatment period] 7 days of hospitalization and 1 week of follow-up by phone
Treatment effect】The condition was significantly controlled and all indicators were improved.
I. Initial consultation
The 65-year-old patient was admitted to the hospital with fever, cough and sputum for 4 days. The patient complained that he had gotten wet during the rain 5 days ago and started to have fever on the second day, with a high body temperature of 38.7℃, accompanied by chills and chills, cough and yellow sputum. He came to our fever clinic, where he was tested negative for novel coronavirus nucleic acid and a chest CT showed right pneumonia.
II. Treatment history
The patient’s chest CT showed right pneumonia. Considering the relatively large area of pneumonia and the patient’s obvious respiratory symptoms, the patient was hospitalized for further treatment in consultation with his family, and asked the patient and his family about his usual physical condition. After admission, the patient’s blood count, PCT, Mycoplasma pneumoniae antibody, and nucleic acid test were completed, and the blood count showed 16.22×10^9/L, 176×10^9/L, 93.2% neutrophil percentage, 141g/L hemoglobin, and 2.39ng/ml calcitoninogen, which showed that the infection index was obviously elevated. The patient was given anti-infective treatment with piperacillin sodium tazobactam sodium for injection, together with the use of pulmonary cough combination for oral administration, and inhalation budesonide suspension and terbutaline sulfate nebulizer for cough and sputum treatment.
III. Treatment effect
Through treatment, the patient’s body temperature dropped to normal at 36.9℃ on the 4th day of hospitalization, and the symptoms of cough and sputum improved significantly. The infection indexes were significantly lower than before. On the 7th day, the patient was in a better mental state and did not complain of any special discomfort, and was discharged successfully. One week after discharge, the patient reported good recovery and did not complain of discomfort.
IV. Notes
We are glad that the patient was cured after treatment. Before the patient was discharged, we told the patient and his family to pay attention to the combination of work and rest, reasonable diet and exercise in daily life. In normal times, family members can make some high vitamin, high protein and easy to digest food for patients, such as vegetable porridge, lean meat porridge, egg custard, freshly squeezed juice, etc., to increase body nutrition and promote body recovery. At the same time, some cold foods can be eaten in moderation to help stop coughing and dissolve phlegm, such as snow pear, loquat, lily, winter melon, etc. If symptoms such as fever, cough and chest pain reappear after returning home with obvious discomfort, you need to follow up promptly at this time to avoid delaying your condition.
V. Personal insight
Pneumonia is one of the common diseases of the respiratory system. It can develop at any age and has a variety of causes and triggers, such as rain, cold, drunkenness, fatigue, etc., so it is important to pay attention to it. It is best to wear a mask to protect the respiratory tract in hazy weather or when going to a heavily polluted area. If symptoms such as difficulty in breathing, coughing, coughing and fever occur, you should seek medical attention to identify the cause of the disease so as not to delay it. For this patient with mild pneumonia, it can be treated by oral antibiotics and the prognosis is good. If it develops into severe pneumonia, it may lead to respiratory failure and cause serious adverse consequences, so treatment should be actively carried out when relevant symptoms appear.