CC: HPI:

O: - What PT was doing, sudden, gradual, or part of chronic. P: - Better or worse (palpation, movement, rest) Q: - Pts. description of pain: sharp, dull, crushing, burning, tearing/ intermittent, constant, throbbing. R: - Where and does it radiate anywhere S: - 0-10, consistent? T: -Timeline: how long, how its changed (better, worse, diff), happened before? ROS: Pert +s and s: -Headache, fever, change in vision, fatigue, weakness, abdominal pain. N/V etc. PMH:
- Medical: - Surgical/Psych: - Meds: - Allergies:

FHx: Social Hx:

Home/Education/Activities: Drugs/Diet: Sex/Suicidality:

Physical Exam:

General Appearance Mr. X is a WDWN ____ seated on a gurney in the ER, breathing comfortably on room air. Breathing was unlabored and accessory muscles were not in use. Vital signs were: T: Pulse: BP: RR: O2sat: Head, Eyes, Ears, Nose, Throat: Lungs: Cardiac: Abdomen: Extremities: Skin: Neurologic Exam:

Lab Results:
Mr. X's lab work was remarkable for:

Summary Statement:
"To Summarize: Mr. H is an HIV + male with a low CD 4 count and high viral load who presents with an acute pulmonary process. The rapid progression

Assessment: 1. 2. 3. The Current plan then is:

+s

-S

Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches.
What else should I include in the differential?, Begin treatment with IV cefuroxime If patient does not show improvement (or worsens) and cultures are unrevealing, consider

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