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)

Findings at re-examination:
- Temperature: 38.8 °C
- Pulse: 102 bpm
- Respiratory rate: 22 /min
- Oxygen saturation: 93% on room air
- Blood pressure: 114/68 mmHg
- General appearance: Pale, visibly unwell, clutching left side with each cough
- Chest auscultation: Clear crackles at left lower lobe (LLL), slightly diminished breath sounds in the same area
- Percussion: Dullness confirmed over LLL

Immediate investigations/results at re-exam:
- CRP: 98 mg/L
- CBC: WBC 13.7 x10^9/L, Neutrophils 9.6 x10^9/L
- ECG: Sinus tachycardia, no ischemia
- Chest X-ray (STAT): Infiltrate in left lower lobe with mild pleural effusion — consistent with community-acquired pneumonia

Working/confirmed impression at re-examination:
- Acute community-acquired pneumonia — left lower lobe
- Pleuritic chest pain secondary to infection
- Non-severe but not suitable for home treatment given hypoxia, systemic signs, and deterioration

Immediate actions taken following re-examination:
- Patient admitted to Danderyds Sjukhus, Internal Medicine Ward (transport: urgent care ambulance)
- Time of hospital admission: 10:15 AM
- Initial inpatient management started (documented subsequently): IV cefotaxime 1 g q8h, oral doxycycline 100 mg BID, paracetamol, IV fluids, short-term supplemental oxygen (2 L/min) and close monitoring.