AIDS & PCP HISTORY_LIST progressive exertional dyspnea fever chills indidious onset of symptoms length of infection since HIV positive prior episodes of PCP dry nonproductive cough prod. white, frothy sputum night sweats prophylatic trimethoprim/ sulfamethoxazole chest pain weight loss headache stiff neck lethargy fatigue weakness malaise diarrhea oral lesions dysphagia odynophagia (painful swallowing) altered mental state skin lesions skin rash anorectal pain vision changes floaters scotomata travel history most recent CD4 count most recent beta 2 microglobulin INFECTIOUS DISEASES etiology of HIV syphillis herpes simplex toxoplasmosis cryptococcus tuberculosis hepatitis CHRONIC DISEASE SYSTEMIC DISORDERS influenza immunization pneumococcal immunization SURGERY PREVIOUS HOSPITALIZATIONS PREVIOUS TESTS baseline ABG SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal MEDS_LAB_TESTS **** MEDS **** LAB Electrolytes BUN creatnine CBC LFT CPK sputum gram stain and PCP stain sputum C&S LDH ESR CD4 count Hepatitis panel VDRL **** TESTS ABG CXR REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge REVIEW_OF_SYSTEMS_3 OB/GYN metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries sagittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty: fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts hospitalization for psychiatric problems personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia PHYSICAL_EVAL_1 VITALS BP Pulse Temp Heart rate GENERAL cachexia SKIN Kopsoi's sarcoma rashes seborrheic dermatitis herpes zoster herpes simplex molluscum contagiosum oral thrush HEENT herpetic lesions oropharyngeal thrush hairy leuoplakia oral Kopsoi's sarcoma retinitis OCULAR LESIONS hemorrhages exudates perivascular white spots cotton wool spots (CMV retinitis) PHYSICAL_EVAL_2 NECK neck rigidity lymphadenopathy CHEST dullness rhonchi decreased breath sounds at bases crackles HEART rhythm murmur ABDOMEN RUQ tenderness hepatoslenomegaly GU candidiasis lesions herpetic lesions ulcers condyloma NEURO motor deficits sensory deficits cranial nerve deficits visual acutiy and visual field deficits (toxoplasmosis) PSYCHIATRIC confusion and disorientation (AIDS dementia complex) DIFF_DIAGNOSIS AIDS PCP pneumonia