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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 — 2025-05-20 @ 09:10 (Patient: Melisa Farrow)
Findings:
- Temperature: 38.8°C
- Pulse: 102 bpm
- Respiratory rate: 22/min
- O2 saturation: 93% (room air)
- Blood pressure: 114/68
- Appearance: Pale, visibly unwell, clutching left side with each cough
- Auscultation: Clear crackles at left lower lobe (LLL); slightly diminished breath sounds in same area
- Percussion: Dullness confirmed over LLL
Laboratory and imaging 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 and mild pleural effusion — consistent with community-acquired pneumonia
Assessment at re-examination:
- Diagnosis confirmed: Acute community-acquired pneumonia (left lower lobe) with pleuritic chest pain. Non-severe overall but not suitable for home treatment due to low O2 saturation, systemic signs, and clinical deterioration.
Immediate actions taken:
- Admitted to Danderyds Sjukhus — Internal Medicine Ward (transport by urgent care ambulance)
- Time of hospital admission: 10:15 AM
- Empiric inpatient treatment started: IV cefotaxime 1 g q8h and oral doxycycline 100 mg BID
- Supportive care: Paracetamol 1 g q6h, IV fluids, supplemental oxygen via nasal cannula (2 L/min initially)
- Monitoring: continuous pulse oximetry and frequent vital checks; repeat labs ordered next morning; plan for step-down to oral therapy and discharge once improving