Input Tokens
650905
Output Tokens
11680
Duration
457476.474
Cost
0
Context
Input
Return the Re-examination of the patient admitted to the hospital 2025-05-20 at 09.10Expected output
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 pneumoniaModel output
**Re-examination of Melisa Farrow (Admitted 2025-05-20 @ 09:10)**
**Chief Findings:**
- **Vital Signs**:
- Temperature: **38.8°C** (febrile)
- Pulse: **102 bpm** (tachycardic)
- Respiratory Rate: **22/min** (tachypneic)
- Oxygen Saturation: **93%** (on room air, requiring supplemental O₂)
- Blood Pressure: **114/68 mmHg**
- **Physical Exam**:
- Appearance: Pale, visibly unwell, clutching left side during coughing.
- **Lungs**: Crackles in the **left lower lobe (LLL)**, diminished breath sounds, **dullness to percussion**.
- **Chest Pain**: Pleuritic (worsened with coughing/deep inspiration).
- **Diagnostic Results**:
- **CRP**: **98 mg/L** (elevated, indicating inflammation/infection).
- **CBC**: **WBC 13.7 x10⁹/L** (leukocytosis), **neutrophils 9.6 x10⁹/L** (neutrophilia).
- **Chest X-ray**: **Left lower lobe infiltrate + mild pleural effusion** (consistent with **pneumonia**).
- **ECG**: Sinus tachycardia, no ischemic changes.
**Diagnosis:**
- **Primary**: **Community-acquired pneumonia (CAP), left lower lobe**.
- **Secondary**: **Pleuritic chest pain** (infection-related).
**Immediate Management:**
- **Admission to Danderyds Sjukhus** (Internal Medicine Ward).
- **Antibiotics**:
- **IV Cefotaxime 1g every 8 hours** (broad-spectrum coverage).
- **Oral Doxycycline 100mg BID** (atypical pathogen coverage).
- **Supportive Care**:
- **Oxygen therapy** (nasal cannula 2 L/min, discontinued after 12h).
- **IV fluids** (mild dehydration).
- **Paracetamol 1g q6h** for fever/pain.
- **Monitoring**: Continuous pulse oximetry, vitals q4h, repeat labs.
**Rationale for Admission**:
- **Oxygen desaturation (93%)** + **systemic symptoms** (fever, tachycardia, leukocytosis) indicated **moderate-severe CAP** unsuitable for outpatient management.
- Risk of **clinical deterioration** (e.g., sepsis, respiratory failure) without close monitoring.
**Follow-Up**:
- Discharged on **2025-05-23** after **48h afebrile**, improved lung sounds, and CRP decline to **31 mg/L**.
- Completed **5-day oral Amoxicillin-Clavulanate** course.
- **Final check-up (2025-05-30)**: Fully recovered; no residual symptoms.