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Abstract: This case describes a 66-year-old patient who presented to our hospital with cough and sputum with dyspnea, along with high sputum, which recently affected normal life and sleep. After completing relevant examinations, the patient was diagnosed with diffuse lesions in both lungs, a common clinical lung injury. Subsequently, the patient was given oxygen and medication, and his symptoms were significantly relieved and his condition gradually recovered.
Basic information】Male, 66 years old
Disease Type】Diffuse lesions in both lungs
Hospital】The First Hospital of Harbin Medical University
Date of consultation】March 2022
Treatment plan】Oxygen inhalation + intravenous infusion (cefoxitin sodium for injection) + nebulizer treatment (aminoglutethimide hydrochloride solution for inhalation)
Treatment period】10 days of hospitalization
Treatment effect】Symptoms were relieved and the condition gradually recovered
I. Initial consultation
The patient is a 66-year-old male who complained of coughing and sputum with dyspnea with no obvious cause 1 week ago, along with high sputum volume, white foamy sputum, about 100ml/day, usually accompanied by shortness of breath, poor sleep at night, aggravated by self-conscious activity, and pain on the right side of the back when breathing deeply or coughing. The CT examination of the lung suggested a solid shadow in the right lower lung, and the preliminary diagnosis was lung injury.
II. Treatment history
The patient was admitted to the hospital with a large amount of coughing sputum, poor mental health and cyanosis of the lips. The results of blood gas analysis showed that the patient’s oxygen saturation level was reduced, and the patient’s white blood cell count and neutrophil count were elevated, which could be considered as a diffuse lesion in both lungs induced by infection.
The patient was given oxygen inhalation to correct the oxygen saturation level and prevent hypoxemia based on the above findings. The patient was also given anti-infective treatment with cefoxitin sodium for injection, together with nebulization treatment with inhaled aminoglutethimide hydrochloride solution, which is beneficial for sputum dissolution.
III. Treatment effect
After the standard drug treatment, the patient’s mental state improved, the cyanosis of mouth and lips was reduced, the shortness of breath was obviously reduced, and the chest pain was alleviated, meanwhile, the patient’s family indicated that the patient’s appetite increased and the sleep state at night was obviously improved. After 10 days of hospitalization, the inflammation index, neutrophil count and white blood cell count were basically normalized, and the patient’s mobility and quality of life were improved, so the patient was discharged.
IV. Notes
We are glad that the patient has basically recovered from the disease, but we still need to advise the patient to avoid passive smoking and contact with polluted environment in daily life; avoid eating spoiled food, pay attention to balanced nutrition in three meals, eat more vegetables and fruits, and eat less greasy and spicy food.
Also, pay attention to maintaining a good state of mind and exercising moderately according to your personal condition to help strengthen your body and prevent the recurrence of infection. In addition, if coughing and phlegm occur again in daily life, you should seek medical examination and follow the medical advice for active treatment.
V. Personal insight
The patient in this article is a patient with lung injury disease caused by infection. Because of the diffuse lesions in both lungs without early treatment, the patient’s condition was prolonged and led to symptoms of obstructed breathing and increased coughing and sputum at a later stage, which even affected normal life activities. Therefore, for elderly patients or those who have suffered from lung diseases, it is important to do regular medical checkups, and if symptoms of unexplained cough, wheezing, and coughing sputum appear, they should be promptly seen and treated early to avoid delaying the disease.