Medical History Summary, Patient Huang XX, male, 83 years old, was admitted to the Department of Orthopedics on December 30, 2022 at 11:47 due to "chest and back pain and limited mobility caused by a fall for 2 days". On January 3, 2023, he was transferred to the ICU for rescue treatment due to symptoms of dyspnea, chest tightness, and difficulty breathing. After being transferred to the ICU, he received endotracheal intubation and assisted ventilation with a ventilator. The test for COVID-19 nucleic acid was positive. For treatment, Western medicine prescribed Su Pu Shen (from 1-3 to 1-18), Linezolid (from 1-11 to 1-25), and Fluconazole (from 1-18 to 1-27) for infection, Azvudine (from1-3 to 1-16) antiviral, as well as symptomatic treatment for phlegm reduction, cough suppression, nebulization for bronchodilation, and anti-inflammatory treatment. The endotracheal tube was removed on January 13, and a thoracentesis was performed on January 18. On January 20, the patient experienced dyspnea and decreased blood oxygen levels again, and was reintubated for assisted ventilation with a ventilator. The treatment plan was changed to Imipenem Sodium + Fluconazole + Linezolid for infection. The endotracheal tube was removed on January 24. On January 29, the patient was transferred to our department (General Medical Department - Traditional Chinese Medicine Classic Ward) for further treatment. All antibiotics were discontinued in Western medicine, and the patient was given medium flow oxygen and enteral nutrition support. Traditional Chinese medicine was the main treatment plan. On January 31, the patient developed low-grade fever, tachypnea, rapid heart rate, scattered moist rales in both lungs, and a chest CT scan showed persistent multiple inflammations in both lungs. Urgent blood gas analysis indicated respiratory failure, and the patient was transferred to our Intensive Care Unit for critical care. Traditional Chinese medicine continued to be the main treatment plan and antibiotics were not administered. On February 7, the patient's condition stabilized and was transferred to a general ward in our department. On February 8, a chest CT scan showed reduced absorption of multiple inflammations in both lungs compared to before. The right pleural effusion decreased, and partial incomplete lung expansion in the lower lobes of both lungs was basically restored. On February 16, the patient's condition improved significantly, and discharge was arranged.,Traditional Chinese Medicine Diagnosis, asthma (shaoyin and taiyin combined syndrome),Western Medicine Diagnosis, severe pneumonia (bacterial, viral) ;acute respiratory distress syndrome;sepsis septic shock;novel coronavirus infection;stage;2 hypertension (extremely high risk) ;type 2 diabetes;compression fracture of the 5th thoracic vertebra;osteoporosis,Intervention Measures, After the patient was transferred to our department, all antibiotics were discontinued, and oxygen therapy and enteral nutrition support were administered. Traditional Chinese medicine combined with external treatment was the main treatment plan. And symptomatic treatment such as blood sugar control, lipid regulation and spot stabilization, and anticoagulation.,Treatment Outcome, The patient's symptoms and oxygenation improved significantly, pulmonary inflammation was significantly reduced, infection indicators decreased significantly, pleural effusion decreased compared to before, and partial incomplete lung expansion in the lower lobes of both lungs was basically restored. The patient's general condition was good after discharge follow-up, with no fever, no obvious cough or sputum, and no wheezing or chest tightness. After being discharged from the hospital, he was followed up by telephone for half a year, and now eats, eats and lives well.
关键词
重症肺炎中医
Keywords
severe pneumoniatraditional Chinese medicine
references
LI Q,GUAN X,WU P,et al. Early transmission dynamics in Wuhan,China,of novel Coronavirus-infected pneumonia.[J].N Engl J Med,2020,382(13):1199-1207.