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Abstract: The subject of this case is Mr. Wang, who developed cough, coughing yellow sputum and fever after getting wet 10 days ago, and his body temperature dropped to normal after taking oral antipyretics. He was given intravenous cefepime hydrochloride for injection and bromohexine hydrochloride for injection at a local clinic 3 days before the consultation, but the above symptoms were not relieved. After consultation, the CT of the lung was completed, suggesting right lung lobar pneumonia, and bronchoscopic aspiration and medication were given.
Basic information】Male, 34 years old
Disease Type】Lobar pneumonia
Hospital】The First Hospital of Harbin Medical University
Time of consultation】April 2022
Treatment plan】Medication (piperacillin sodium sulbactam sodium for injection, levofloxacin hydrochloride injection, ambroxol hydrochloride sodium chloride injection, eucalyptus citrulline enteric capsules)
Treatment period】7 days of inpatient treatment, outpatient follow up
Treatment effect】The condition has been controlled, and all indicators are improving
I. Initial consultation
Mr. Wang developed cough, yellow sputum and fever after getting wet 10 days ago, and his body temperature was up to 40℃, which dropped to normal after taking oral antipyretics, accompanied by chest tightness and shortness of breath. 3 days ago, he developed obvious chest pain, especially when taking deep breaths, and had a severe cough. The CT of the lung was completed, suggesting: right lung lobar pneumonia. Combined with the medical history and imaging examination, the diagnosis of lobar pneumonia was made. Mr. Wang was admitted to the hospital with cough, high sputum volume, obvious chest pain and persistent high fever.
II. Treatment history
Mr. Wang developed high fever after getting cold in the rain before the onset of the disease, and later developed cough, coughing yellow sputum with high volume and obvious chest pain, accompanied by headache and poor mental status. After admission to the hospital, respiratory pathogen detection, blood gas analysis, blood routine, calcitoninogen, and electronic bronchoscopy were completed. Blood gas analysis suggested: hypoxemia; blood routine suggested: increased leukocytes. We communicated with Mr. Wang and his family about his condition and informed them about the precautions related to lobar pneumonia, etc. After fully communicating with Mr. Wang and his family about the risks and necessity of bronchoscopy, bronchoscopy was performed, and a large amount of secretion was seen to obstruct the airway under the microscope. Diet, strengthen nutrition, etc.
(Blood count)
(Bronchoscopy)
III. Treatment effect
After adopting the above treatment measures, Mr. Wang’s blood gas analysis showed that the hypoxemia was corrected. Body temperature returned to normal, cough and sputum symptoms were significantly reduced, and sputum volume was significantly reduced. The routine blood test showed that all indicators were basically normal. In conclusion, Mr. Wang’s symptoms have disappeared, and he was discharged from the hospital with clinical cure.
IV. Notes
I am glad that after the treatment, Mr. Wang’s symptoms have improved significantly and the indexes have basically returned to normal. In daily life, avoid overexertion, cold, flu and rain. Diet, reasonable meals, strengthen nutrition, eat foods rich in nutrients, such as eggs, milk, lean meat, beef, etc., and also eat more fresh vegetables and fruits to improve the body’s resistance. Streptococcus pneumoniae vaccination can be given if your body is in condition to prevent lung infections. After discharge from the hospital, follow the doctor’s instructions to regularly review blood tests and lung imaging to prevent recurrence of the disease.
V. Personal insight
Lobar pneumonia is an inflammation of the alveoli in one lobe or lung segment caused by bacteria such as Streptococcus pneumoniae and Haemophilus influenzae, and is often triggered by cold, fatigue, and intoxication. Complications of lobar pneumonia are rare, but lung abscess, abscess chest or pneumothorax can occur if the treatment is not timely, the pathogenic bacteria are virulent or the organism is overly reactive, and severe infection with bacteria multiplying in the blood and spreading can lead to sepsis. As we know from this case, we should do our best to keep warm and avoid getting wet. If symptoms such as high fever and cough appear after getting wet, do not take it lightly, but seek medical advice and treat the symptoms promptly.