NR 603 Week 5 iHuman Virtual Patient Encounter and Reflection - Charlie Harris - Attempt 3880969
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History Notecard by Dikshya Poudel on case Charlie Harris Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient’s reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using OLDCARTS. Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient’s age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = Sx = Sx = Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity Attempt: 3880969 Report generated on 4/5/2026, 11:42:13 PM America/Denver Management Plan by Dikshya Poudel on case Charlie Harris Subjective The patient is a 39-year-old male with untreated HIV who reports a two-week history of progressively worsening exertional dyspnea, now present with minimal activity and during conversation. Associated symptoms include fever, night sweats, nonproductive cough, and unintentional weight loss. He denies chest pain, wheezing, dizziness, recent travel, or sick contacts. Albuterol use did not provide relief. Objective Vital signs: Evaluate for fever, tachypnea, tachycardia, and hypoxemia Pulse oximetry: Likely decreased oxygen saturation Physical exam: Possible tachypnea, use of accessory muscles, and cervical lymphadenopathy Assessment Findings are highly suggestive of Pneumocystis pneumonia (PCP) in the setting of untreated HIV infection and possible likely immunosuppression (CD4 92%, continues for hypoxemia and until being transferred to a higher level of care or the emergency room (Reizine et al., 2025). Acetaminophen 500–650 mg PO every 6 hours as needed for fever First-line therapy (moderate to severe PCP): Trimethoprim-sulfamethoxazole (TMP-SMX) Prescription: TMP 15–20 mg/kg/day and SMX 75–100 mg/kg/day IV divided every 6–8 hours for 21 days (Elango et al., 2022). Transition to oral therapy when clinically stable Adjunctive corticosteroids (if PaO₂
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