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Abstract: This 21-year-old young female patient presented with fever, peripheral chills and other symptoms 3 hours later, she developed chest tightness and breath-holding symptoms, and was seen in our hospital. After completing blood analysis and chest CT and other examinations, viral pneumonia, a common viral disease in clinical practice, was considered, and after treatment with oxygen inhalation, nebulized inhalation and intravenous fluids, the patient’s discomfort disappeared and she basically recovered.
Basic information】Female, 21 years old
Type of disease】Viral disease
Hospital】Beijing Huairou District Hospital of Traditional Chinese Medicine
Date of consultation】March 2022
Treatment plan】Medication (acetaminophen tablets + 0.9% sodium chloride solution + vitamin C injection + recombinant human interferon alpha 2b injection + ribavirin injection + ribavirin tablets + Jinhua Qingqi granules)
[Treatment cycle] 16 days of outpatient treatment, review after 2 months
Treatment effect】The patient’s symptoms disappeared and her condition basically recovered.
I. Initial consultation
The patient is a 21-year-old female, complaining of discomfort at 1:00 a.m., with peripheral fever, untested temperature, peripheral chills with pain, headache, dry cough and other symptoms, and a weak mental state, and chest tightness and breath-holding sensation at 4:00 a.m. The patient was asked to complete blood analysis, and no abnormality was found; chest CT examination suggested diffuse ground glass shadow in both lungs, oxygen saturation was measured at 92%, and body temperature was 38.5℃.
II. Treatment history
Considering that the patient’s pneumonia was relatively serious and his blood oxygen was low, he was admitted to the observation ward for bed rest and given oxygen inhalation to improve the symptoms of chest tightness and breath-holding. Since the patient’s fever was not serious, the patient was given acetaminophen tablets to reduce fever, and 0.9% sodium chloride solution plus vitamin C injection was given intravenously for rehydration to enhance resistance.
At 8:00 a.m., the patient tested negative for mycoplasma, which basically confirmed the diagnosis of viral pneumonia, and was given recombinant human interferon α2b injection for nebulized inhalation and ribavirin injection for intravenous antiviral treatment. After 24 hours of observation, the patient’s temperature dropped to 37.1℃ and oxygen saturation increased to 96%. The patient’s family signed a refusal to continue observation and went home. The patient and his family were instructed to continue outpatient intravenous fluids and nebulizer treatment, and to consult the doctor promptly if there was any increase in chest tightness.
III. Treatment effect
After 3 days of outpatient treatment, the patient’s body temperature returned to normal, and symptoms such as peripheral chills and pain disappeared. After 5 days of treatment, the dry cough was basically improved, no chest tightness and breath-holding were seen, and the blood oxygen was 98%. After 9 days of treatment, the inflammation of chest CT was basically restored, and the nebulized inhalation of recombinant interferon α2b injection and intravenous drip of ribavirin injection were stopped.
IV. Notes
We are glad that the patient recovered from the disease. As the patient said before that her health was poor, her life and rest were irregular, and she had been on a diet for one month before the disease, so her body resistance became poor. Therefore, it is recommended that the patient should increase physical exercise, avoid staying up late, get enough sleep, and enhance nutrition at three meals to replenish the vitamins and energy needed by the body after discharge from the hospital. When going out, pay attention to wearing a mask to protect yourself and reduce the occurrence of diseases.
V. Personal insight
Viral pneumonia is a disease that progresses relatively quickly. In this case, the patient’s lungs were already severely inflamed after only about 3 hours from the onset of symptoms to the time of consultation, which is more rapid than other viral pneumonia patients.
We often tell patients that 1/3 of viral diseases rely on medication, 1/3 rely on their own body’s resistance, and the remaining 1/3 rely on recuperation and nutritional supplements after getting sick. If the patient’s body resistance is relatively strong, the virus infection may be a viral cold and will not develop into pneumonia, or even any uncomfortable symptoms.