Context Reasoning

Return the Re-examination of the patient admitted to the hospital 2025-05-20 at 09.10

Temperature: 38.8°C, Pulse: 102 bpm, Respiratory Rate: 22/min, O2 Sat: 93% (room air), BP: 114/68, Appearance: Pale, visibly unwell, clutching left side with each cough, Auscultation: Clear crackles LLL (Left Lower Lobe), slightly diminished breath sounds in same area, Percussion: Dullness confirmed, CRP: 98 mg/L, CBC:, WBC: 13.7 x10⁹/L (elevated), Neutrophils: 9.6 x10⁹/L, ECG: Sinus tachycardia, no ischemia, Chest X-ray (STAT reading):, Infiltrate in left lower lobe, mild pleural effusion, Consistent with community-acquired pneumonia

    **Re-examination of Patient Admitted 2025-05-20 at 09:10 (Melisa Farrow)**

    **Chief Complaint at Re-examination:**
    - Worsening symptoms overnight: **fever (38.8°C)**, **chills**, **increased pleuritic chest pain** (left-sided, exacerbated by coughing), and **dizziness**.
    - **O₂ saturation dropped to 93%** (from 96% on 2025-05-19).

    **Key Findings:**
    1. **Vital Signs:**
       - Temperature: **38.8°C** (febrile)
       - Pulse: **102 bpm** (tachycardic)
       - Respiratory Rate: **22/min** (tachypneic)
       - BP: **114/68 mmHg**
       - O₂ Saturation: **93%** (on room air, requiring supplemental oxygen later).

    2. **Physical Examination:**
       - **Appearance**: Pale, visibly unwell, clutching left side during coughing.
       - **Lungs**:
         - **Crackles** in the **left lower lobe (LLL)**.
         - **Diminished breath sounds** in LLL.
         - **Dullness to percussion** over LLL (suggestive of **consolidation/pleural effusion**).
       - **Cardiac**: Sinus tachycardia (ECG normal, no ischemia).

    3. **Diagnostic Results:**
       - **Chest X-ray**: **Infiltrate in LLL + mild pleural effusion** → **community-acquired pneumonia (CAP)**.
       - **Labs**:
         - **CRP: 98 mg/L** (markedly elevated, indicating inflammation/infection).
         - **WBC: 13.7 x10⁹/L** (leukocytosis), **Neutrophils: 9.6 x10⁹/L** (neutrophilia).
         - Rapid viral panel (SARS-CoV-2/Influenza): **Pending** (not yet reported in this entry).

    **Diagnosis:**
    - **Primary**: **Acute community-acquired pneumonia (CAP) – Left lower lobe**.
    - **Secondary**: **Pleuritic chest pain** (due to pleural inflammation/effusion).
    - **Severity**: **Non-severe CAP** but **not suitable for outpatient treatment** due to:
      - Hypoxemia (O₂ sat 93%).
      - Systemic symptoms (fever, tachycardia, elevated CRP/WBC).
      - Worsening clinical status.

    **Immediate Management:**
    1. **Hospital Admission** (Danderyds Sjukhus, Internal Medicine Ward) via **urgent ambulance transport**.
    2. **Antibiotics**:
       - **IV Cefotaxime 1g every 8 hours** (broad-spectrum coverage for CAP).
       - **Oral Doxycycline 100mg BID** (added for atypical pathogen coverage).
    3. **Supportive Care**:
       - **Oxygen therapy** (nasal cannula 2 L/min for 12 hours).
       - **IV fluids** (mild dehydration).
       - **Paracetamol 1g q6h** for fever/pain.
    4. **Monitoring**:
       - Continuous pulse oximetry.
       - Vitals every 4 hours.
       - Repeat labs (CRP, CBC) the following morning.

    **Prognosis & Plan:**
    - **Expected Improvement**: Step-down to oral antibiotics within **24–48 hours** if afebrile and clinically stable.
    - **Discharge Criteria**: Afebrile for ≥24h, normal O₂ saturation off supplemental oxygen, tolerating oral intake, and improving lung exam.
    - **Follow-up**: Scheduled for **2025-05-30** with GP (Dr. Arvid Lindholm) to confirm resolution.

    **Clinical Note:**
    - Early admission was critical due to **rapid deterioration** (from mild symptoms on 2025-05-19 to hypoxemia/pleural effusion on 2025-05-20).
    - **Ibuprofen use prior to admission** may have masked fever and delayed diagnosis.
    - Patient advised to **avoid NSAIDs during future unexplained infections** and seek **prompt evaluation for recurrent cough/chest pain**.