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Abstract: A 72-year-old male patient reported that 6 days ago, he developed chest tightness and shortness of breath with no obvious cause, presenting with a feeling of suffocation in the precordial region, which was mild and severe at times and could be aggravated after activity, without accompanying nausea, vomiting, cough, palpitations, dizziness, etc. He went to the hospital for consultation and treatment because the discomfort was not relieved continuously. After systematic examination, he was diagnosed as having angina pectoris, and his condition was controlled by medication.
Basic information】Male, 72 years old
Disease Type】Angina pectoris
Hospital】Central South University Xiangya Hospital
Date of consultation】June 2022
Treatment plan】Medication (nitroglycerin tablets, propranolol hydrochloride tablets)
Treatment Period】11 days of in-hospital treatment
Effectiveness】The condition was controlled and the symptoms of chest tightness and shortness of breath improved.
I. Initial consultation
The first time I saw the patient, the patient reported that 6 days ago, he suddenly felt chest tightness and shortness of breath, with a feeling of suffocating in the precordial area, which was sometimes mild and heavy, and could be aggravated after activity, and the discomfort lasted for several minutes. The patient’s history of bronchitis and cervical spondylosis was revealed after detailed questioning. During physical examination, the patient was found to have coarse breath sounds on auscultation of both lungs, and no bilateral lower limb edema, pericardial friction, or pathological murmur was found.
II. Treatment history
After the diagnosis was confirmed, I fully communicated with the patient and suggested that the patient should take medication as soon as possible in order to control the disease and prevent the disease from progressing to the detriment of his health or even endanger his life. I first prescribed nitroglycerin tablets, which can make the patient’s blood vessels dilate and make the myocardium consume less oxygen, thus reducing the adverse symptoms induced by angina pectoris, and let the patient take propranolol hydrochloride tablets, which can relieve the myocardial ischemia and hypoxia brought about by the disease, thus improving the symptoms of chest tightness and shortness of breath.
III. Treatment effect
On the first day of in-hospital treatment, the patient reported that the symptoms of chest tightness and shortness of breath were lighter than when he was admitted to the hospital, and there were no other adverse symptoms. On the 11th day of in-hospital treatment, the patient reported that the symptoms of chest tightness and shortness of breath had improved and he could not feel any discomfort, and his body temperature was 36.6℃, blood pressure was 121/76mmHg, both lungs were clear on percussion, and there was no feeling of pericardial friction.
IV. Notes
The patient was happily discharged after her condition was well controlled. I was sincerely happy for the patient, but at the time of discharge, I also advised the patient to pay attention to the following matters.
1, should maintain a light diet, appropriate to eat more vegetables, fruits, beans, meat food, to ensure a balanced daily nutritional intake, avoid intake of spicy and stimulating and greasy food, to prevent improper diet and interference with the recovery rate of the disease.
2, life should pay attention to warmth, daily appropriate activities with their own situation, such as slow walking, tai chi, etc., to help improve their own physical condition.
3. I repeatedly advised the patient to take the medication prescribed by me on time after discharge from the hospital and to consult the doctor immediately when he/she is not feeling well.
V. Personal insight
Angina pectoris is a relatively serious disease, the impact on their own health is also greater, if the continued failure to take treatment measures, the disease will progress and even endanger their lives, so it is recommended that patients suffering from such diseases timely medical treatment, the doctor combined with their condition to take targeted measures. Like the 72-year-old male patient in this case, his condition has been stabilized after treatment due to timely detection of the disease.