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Abstract: The patient in this case is a middle-aged woman with Silhan’s syndrome who suddenly developed cough and sputum and other uncomfortable symptoms in the last few days. After poor treatment with local medication, she came to our hospital and was diagnosed with bronchopneumonia after relevant examination.
Basic information】Female, 55 years old
Disease Type】Bronchopneumonia
Hospital】The First Hospital of China Medical University
Date of consultation】April 2019
Treatment plan】Oral medication (prednisone acetate tablets, levothyroxine sodium tablets) + intravenous injection (cefotaxime sodium for injection, bromohexine hydrochloride injection) + nebulized inhalation (acetylcysteine solution for inhalation)
Treatment period】Hospitalization for 10 days, continuous outpatient follow up
Treatment effect】The condition improved, and the discomfort symptoms basically disappeared.
I. Initial consultation
The patient, 55 years old, complained of Silhan’s syndrome for 30 years and was taking prednisone acetate tablets and levothyroxine sodium tablets. He was treated with infusion in local outpatient clinic for 2 days (specific medication is not known), which was not effective and still coughing sputum. In the past 2 days, the patient had abdominal distension, poor appetite, occasional vomiting, and no diarrhea or black stool. Combined with the patient’s complaints, a physical examination was performed in the outpatient clinic, which showed clear sounds on percussion of both lungs, coarse breath sounds in both lungs, and audible wet rales at the base of the left lung; CT examination of the chest showed increased disorder of texture in both lungs, and patchy hyperdensity shadow with blurred edges in the lingual and lower lobes of the left lung.
II. Treatment history
According to the patient’s condition, relevant auxiliary examinations such as arterial blood gas analysis were improved and differential diagnosis was made after admission. We introduced the patient’s condition and the proposed treatment plan to the patient and his family, who agreed. The patient was then given oxygen, cardiac monitoring, regular administration of prednisone acetate tablets and levothyroxine sodium tablets for the treatment of Silhan’s syndrome, and intravenous injection of cefotaxime sodium for injection to fight against infection, drip injection of bromohexine hydrochloride, and nebulization of acetylcysteine solution for inhalation to dilute sputum and promote sputum excretion. The patient’s vital signs were closely monitored, and the temperature changes were continuously monitored.
III. Treatment effect
After 7 days of active medical treatment, the patient complained of no episodes of chest tightness and chest pain, and her appetite was better than before admission, and she did not experience any discomfort such as abdominal distension and vomiting after a small amount of meals, but she still had a cough, and her coughing sputum was less than before, and her sputum was thinner than before admission. Continuous cardiac monitoring also showed stable vital signs, and no significant rales were heard in both lungs during physical examination, and the heart rate was 64 beats/min. After 10 days of hospitalization, he had occasional coughing and slept well at night in a flat position, and the re-examination of CT showed normal lungs and no significant abnormalities, indicating a good treatment effect.
IV. Notes
I was very happy to see that the patient’s condition improved, bronchopneumonia was under control, and his appetite returned to normal. Combining with the patient’s symptoms and signs, I agreed that the patient should recuperate at home after 10 days of hospitalization. The patient was also instructed that after discharge, he could take proper nutrition and increase the intake of protein and vitamins, such as eggs, milk, tofu and other foods; and that he should insist on taking prednisone acetate tablets levothyroxine sodium tablets for the treatment of Silhan’s syndrome and should not stop the medication on his own. In addition, when you travel daily, you should pay attention to protection and add clothes appropriately according to the weather conditions to avoid catching cold to induce bronchopneumonia again.
V. Personal insight
Bronchopneumonia is mainly caused by infection, and it occurs in people with poor health like the patient in this case. These people should be well protected from cold and cold in their daily life, and they should also actively participate in physical exercise to improve their health. If once there is a cough, coughing phlegm. Chest pain and other symptoms, it is recommended that the first time to the regular hospital, according to the results of the examination for targeted treatment, so as not to delay the time of treatment.