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 — 2025-05-20 @ 09:10**

**Patient:** Melisa Farrow
**Location:** Danderyds Vårdcentral, Urgent Care Slot

**Vital Signs:**
• Temperature: 38.8°C
• Pulse: 102 bpm
• Respiratory Rate: 22/min
• O2 Saturation: 93% (room air)
• BP: 114/68

**Appearance:** Pale, visibly unwell, clutching left side with each cough

**Physical Examination:**
• Auscultation: Clear crackles LLL (Left Lower Lobe), slightly diminished breath sounds in same area
• Percussion: Dullness confirmed

**Lab Results:**
• CRP: 98 mg/L
• CBC - WBC: 13.7 x10⁹/L (elevated)
• CBC - 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

**Confirmed Diagnosis:**
• Acute community-acquired pneumonia (CAP) — Left lower lobe
• Pleuritic chest pain secondary to infection
• Status: Non-severe CAP but not suitable for home treatment due to oxygen saturation, systemic signs, and worsening symptoms

**Action Taken:**
• Admitted to Danderyds Sjukhus – Internal Medicine Ward at 10:15 AM via urgent care ambulance