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Abstract: A 76-year-old male patient reported that he had symptoms of chest tightness and shortness of breath with no obvious cause for the past 4 days, and the discomfort was more pronounced during activities, stair climbing and emotional stress, lasting for about several minutes each time, and was suddenly accompanied by coughing and weakness today. After systematic examination, he was diagnosed with heart failure, and his disease has been better controlled with medication.
Basic information】Male, 76 years old
Disease Type】Heart Failure
Hospital】Central South University Xiangya Third Hospital
Date of consultation】June 2022
Treatment plan】Medication (hydrochlorothiazide tablets, digoxin tablets)
Treatment period】In-hospital treatment for 5 days, followed by discomfort
Treatment effect】The disease was well controlled, and the symptoms of chest tightness, shortness of breath, coughing, weakness and lower limb edema disappeared.
I. Initial consultation
When we first saw the patient, he reported that he suddenly felt chest tightness and shortness of breath 4 days ago, and the discomfort lasted for several minutes, and became more obvious when he was moving, climbing stairs, or under emotional stress. When asked about his condition, he was told that he had a past history of type 2 diabetes and gallbladder polyps, and that he was taking his medications regularly. The physical examination revealed a small amount of wet rales in both lungs, coarse breath sounds in both lungs on auscultation, moderate edema in both lower extremities, and systolic murmurs in the mitral valve area, but no obvious pathological murmurs in the remaining valves on auscultation.
II. Treatment process
I first informed the patient of the diagnostic results and suggested that the patient should take targeted treatment measures as soon as possible. Because the patient’s condition was not very serious and he was old, he was not treated surgically, but was advised to take medication. I put the patient on hydrochlorothiazide tablets, which have diuretic effect and can effectively improve the edema of the patient’s lower limbs. In addition, the patient’s heart contraction ability and myocardial ejection function were weakened due to the disease. To improve his cardiac abnormalities, I also prescribed cardiac drugs, namely digoxin tablets, and no adverse symptoms were observed after the treatment with these two drugs.
III. Treatment effect
After conventional in-hospital drug treatment, the patient’s physical symptoms slowly became less severe, and each examination result was better than the previous one, without other obvious abnormal symptoms. On the 5th day of in-hospital treatment, the patient reported that the symptoms of chest tightness, shortness of breath, coughing, weakness, and lower limb edema disappeared, the heart rate was 79 beats/min, blood pressure was 128/68 mmHg, the patient’s consciousness was clear, the percussion was clear, and no wet rales were heard in both lungs.
IV. Notes
The patient was satisfied with the results of the treatment, and I was very happy when the patient was discharged happily. In order to make the patient recover better, I advised the patient to take regular rest and rest time, balanced diet and nutrition, quit smoking and drinking, and increase and decrease clothing appropriately with weather changes to prevent the body from getting cold and aggravating the disease.
I also advised the patient that although the disease was under control, it could not be said to be cured, and that he should take his medication regularly after discharge, and that he should review his condition with his doctor to adjust his medication in the light of his recovery. In addition, if there is any physical discomfort, you should seek medical attention immediately.
V. Personal insight
The causes of diseases and symptoms of discomfort are complex, and the symptoms of some diseases are not typical, so it is easy to be misdiagnosed and delay the treatment. Like the 76-year-old male patient in this case, he sought medical treatment in time after resting and not seeing any relief. I think this practice is worth advocating, which helps early detection, early diagnosis and early treatment of the disease and has a better prognosis.