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Abstract: Patient Lao Liu, 69 years old, presented to our hospital with a recent unprovoked fever, muscle aches, and malaise. After the patient was admitted to the hospital, he was treated with symptomatic intravenous fluids and oral medication, and his condition is now basically stable.
Basic information】Male, 69 years old
Type of disease】Klebsiella pneumoniae sepsis
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】September 2020
Treatment plan】Intravenous infusion (ceftazidime for injection, imipenem cistatin sodium for injection, cefoperazone sodium sulbactam sodium for injection) + oral medication (ibuprofen tablets)
[Treatment period] 2 weeks in hospital
Effectiveness of treatment】The patient’s antibacterial treatment was successful, and the symptoms were cleared.
I. Initial consultation
Patient Liu, 69 years old, recently developed fever, muscle pain and weakness without any obvious cause, and came to our hospital because his symptoms had affected his normal life.
The patient reported a brief fever remission after taking roxithromycin at home, but a relapse soon occurred. The patient’s basal signs were measured in the clinic and showed a temperature of 39.1°C, blood pressure of 170/110 mmHg, and heart rate of 95 beats/min, with significant fever and hypertension.
The patient reported that he had been taking amlodipine besylate tablets to control his blood pressure. The patient’s recurrent fever was initially considered to be due to infection. To further clarify the cause of the patient’s illness, he was admitted to our hospital for examination.
II. Treatment
After admission, the patient was examined. The patient’s consciousness was clear, the skin and sclera did not show abnormal symptoms, and the superficial lymph nodes were not palpated. The patient was examined by palpation, and the results indicated a mild abdominal bulge, coarse breath sounds on lung auscultation, and percussion pain in the liver and right kidney area.
The patient’s blood was drawn for bacterial culture, suggesting Klebsiella pneumoniae infection, and a clear diagnosis of Klebsiella pneumoniae sepsis was made. The patient was given a drug sensitivity test to further determine the medication to be used. At the beginning, the patient was given ceftazidime for injection, and after observing that the treatment effect was not obvious, the patient was then switched to imipenem cistatin sodium for injection intravenously according to the results of the drug sensitivity test. After changing the drug, the patient’s body temperature began to gradually decrease. After the patient’s condition improved, he was switched to cefoperazone sodium sulbactam sodium for injection intravenously for anti-infection treatment, as well as oral ibuprofen tablets to play the role of anti-inflammatory and antipyretic.
III. Treatment effect
After 2 weeks of inpatient treatment, the patient’s symptoms were significantly better than those seen in the hospital, such as temperature and other basic signs were controlled within the normal range, and the patient’s previous symptoms of fever, muscle aches and weakness without any cause were resolved.
IV. Notes
I was relieved to see that the patient’s symptoms were gradually reduced, but for the sake of the patient’s health, I still need to remind the patient to pay attention to some matters in daily life: 1.
1, remind the patient that the diet needs to be rich in high-quality protein, such as animal protein, including chicken, pork, beef, etc., and some plant plant protein, mainly black beans, mung beans, etc. in legumes.
2, the daily diet as far as possible to do less and more meals, to develop good eating habits, to avoid overeating. At the same time, patients need to pay attention to their own body temperature at all times in daily life to avoid the emergence of sudden phenomena.
V. Personal insight
Klebsiella pneumoniae sepsis is usually secondary to the presence of Klebsiella pneumoniae infection, and the susceptibility of Klebsiella pneumoniae is usually diabetic patients, patients with malignancy, antibiotic application, and the elderly or newborns. Since this disease mostly occurs when the patient’s body resistance decreases, patients are reminded to keep exercising to improve their immunity, and in the case of the patient in this case, because of his age, it is sufficient to exercise appropriately on a daily basis.