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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
- 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 x10^9/L (elevated); Neutrophils 9.6 x10^9/L
- ECG: Sinus tachycardia, no ischemia
- Chest X-ray (STAT reading): Infiltrate in left lower lobe, mild pleural effusion
DIAGNOSIS (CONFIRMED)
- 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
ACTIONS
- Admitted to: Danderyds Sjukhus – Internal Medicine Ward
- Time of admission: 10:15 AM
- Antibiotics Initiated:
• IV Cefotaxime 1 g every 8h
• Oral Doxycycline 100 mg BID (at physician's discretion, due to atypical presentation overlap)
- Supportive Treatment:
• Paracetamol 1 g q6h for fever and pleuritic pain
• IV fluids (mild dehydration suspected)
• Oxygen via nasal cannula (2 L/min) during first 12h (O2 sat normalized after)
Monitoring:
- Continuous pulse ox, vitals every 4h
- Repeat labs ordered for next morning
- Discharge planned based on 48h improvement window
WARD NOTES
- Patient clinically stable overnight. Fever resolving. Cough remains but improved. Step-down to oral therapy within 24h and discharge within 48–72h total if progress continues.