HPIInfection

  • [01] [3] CC: [var:age-number] year old [M,F,transgender,__;var_gender] with [ ,no,__;var_nopmh] pertinent PMH/PSH [ ,__;var_pmh] 
  • [01] presents with chief compliant of
    • Infection
    • Sepsis
    • Hypotension
    • AMS
    • Rash
    • Cough
    • Fever
    • Dysuria
    • Nausea/Vomiting
    • __
  • [01] [1] Hx:
    • Upon interview of patient regarding the following potentially infectious symptoms, the pt:
      • __
      • [01] [denies,endorses,__;hpi_1] fevers,
      • [01] [denies,endorses,__;hpi_2] headache,
      • [01] [denies,endorses,__;hpi_3] neck stiffness,
      • [01] [denies,endorses,__;hpi_4]cough,
      • [01] [denies,endorses,__;hpi_5] SOB,
      • [01] [denies,endorses,__;hpi_6] chest pain,
      • [01] [denies,endorses,__;hpi_7] abdominal pain,
        • in RUQ
        • in RLQ
        • in LUQ
        • in LLQ
        • diffusely
        • __
      • [01] [denies,endorses,__;hpi_8] nausea/vomiting,
      • [01] [denies,endorses,__;hpi_10] diarrhea,
      • [01] [denies,endorses,__;hpi_11] rash,
      • [denies,endorses,__;hpi12] female specific complaints:
        • [denies,endorses,__;hpi_13] vaginal discharge,
        • [denies,endorses,,__;hpi_14] hx of STI,
        • [denies,endorses,__;hpi_15] high risk sexual risk behavior,
        • [denies,endorses,,__;hpi_16] pelvic pain,
      • [denies,endorses,__;hpi_17] male specific complaints:
        • [denies,endorses,__;hpi_18] testicular pain,
        • [denies,endorses,__;hpi_19] penial discharge,
        • [denies,endorses,__;hpi_20] epidemial pain,
        • [denies,endorses,__;hpi_21] hx of STI,
        • [denies,endorses,__;hpi_22] lesions in groin,
    • [01] [1] Hx regarding immunosuppression:
      • [01] Pt denies any knowledge of immunosuppression. 
      • Unknown HIV
      • States no HIV
      • HIV +
        • Last CD4
          • __
        • On HAART
          • __
      • Malignancy
        • Known malignancy
        • No known malignancy
        • On chemo
          • last chemo
        • Not on chemo
      • IVDU
      • frequent etoh use
      • Hx of TB
      • chronic steroid use
      • __

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