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Abstract: The patient is a female, 15 years old, with symptoms of itchy throat, dry throat, nasal congestion and yellow runny nose after getting cold 7 days ago, and cough, small amount of mucous sputum, chest tightness and shortness of breath in the last 4 days. Combined with electrocardiogram and frontal and lateral chest radiographs, she can be diagnosed as bronchitis, i.e. acute bronchitis. After regular medication as well as general conditioning treatment, her condition is basically stable, and the symptoms of cough, sputum, itchy throat and runny nose are significantly reduced.
Basic information】Female, 15 years old
Type of disease】Bronchitis (acute bronchitis)
Hospital】The First Hospital of China Medical University
Date of consultation】November 2019
Treatment plan】Oral medication (dextromethorphan hydrobromide tablets, oral solution of ambroxol hydrochloride)
Treatment period】Hospitalization for 3 days, rechecked after 1 week
【Treatment effect】The disease was basically stable, and the symptoms of cough, coughing, itchy throat and runny nose were significantly reduced
I. Initial consultation
The patient reported that he had symptoms of itchy throat, dry throat, nasal congestion, yellow runny nose and low fever after getting cold 7 days ago, and coughing, coughing a small amount of white mucous sputum, headache, dull pain in the chest, nausea, chest tightness and shortness of breath without any cause 4 days ago. In order to seek further treatment, he came to our hospital. The physical examination showed normal vital signs, clear percussion of both lungs and coarse breath sounds, and the orthopantomogram of the chest showed no obvious abnormalities in the heart, lungs and diaphragm, and patchy soft tissue density foci were seen in the anterior superior mediastinum, and the ECG was a normal ECG, which could be diagnosed as bronchitis (acute bronchitis).
II. Treatment history
The patient’s frontal and lateral chest films showed abnormal density foci in the anterior superior mediastinum, and the residual thymus gland was considered, suggesting that the thymus gland did not degenerate completely during the growth and development process, which is a normal phenomenon and will degenerate gradually afterwards, so no special treatment was carried out for the time being. For the patient’s symptoms of white mucous sputum and yellow sputum, dextromethorphan hydrobromide tablets were given to relieve the cough symptoms, and aminophenazone hydrochloride oral solution was given to dilute the sputum well. To address the patient’s symptoms of low fever, he was advised to take cefuroxime tablets. After 3 days of admission, the condition was basically stable, and no drug side effects appeared during the period, so the patient was given discharge treatment and was rechecked 1 week after discharge.
III. Treatment effect
After 3 days of drug treatment, the patient’s cough, itchy throat, runny nose and chest pain subsided, physical examination: body temperature was normal, spirit was fine, sputum volume was small and white, urine and stool were normal. The treatment effect was good and the patient was satisfied, so he was discharged from the hospital with no other discomfort symptoms.
IV. Precautions
I am very happy that the patient’s condition is basically stable after regular medication and general care treatment, but the following matters still need to be noted.
1. After discharge from the hospital, the patient should pay attention to nutritional supplementation, choosing fresh vegetables and fruits rich in vitamins and foods rich in high-quality protein to supplement the nutrients required by the human body on a daily basis, which will help the recovery of the disease.
2, in daily life need to pay attention to the weather conditions in a timely manner to increase and reduce clothing, to prevent colds, to avoid the recurrence of disease caused by cold.
3.After discharge from the hospital, we need to monitor our own condition in time. If patients have uncomfortable symptoms such as itchy throat, dry throat, nasal congestion and yellow runny nose, it is recommended to actively seek medical consultation at the hospital.
V. Personal insight
Bronchitis is a relatively common respiratory disease that often occurs when the body’s resistance decreases after a cold, as in the case of this patient. However, if the disease is not treated in time, it may develop into chronic bronchitis, which is relatively longer and more harmful to the body. Therefore, if symptoms such as cough, dry throat and itchy throat appear, seek medical attention in a timely manner to avoid delaying the best time for treatment.