WITH a (PID,VisitType,Rn,RowNo)

AS (

SELECT PID,VisitType,Rn

,ROW_NUMBER() OVER (PARTITION BY PID,Rn ORDER BY VisitType ASC)

FROM @PatDev

),

b (PID,MaxRowNo)

AS (

SELECT PID,MAX(RowNo)

FROM a

GROUP BY PID

)

SELECT b.PID

,MAX(CASE WHEN c.C = 1 THEN ISNULL(a2.VisitType,a.VisitType) END) AS [Col1]

,MAX(CASE WHEN c.C = 2 THEN ISNULL(a2.VisitType,a.VisitType) END) AS [Col2]

,MAX(CASE WHEN c.C = 3 THEN ISNULL(a2.VisitType,a.VisitType) END) AS [Col3]

,MAX(CASE WHEN c.C = 4 THEN ISNULL(a2.VisitType,a.VisitType) END) AS [Col4]

FROM b

JOIN (SELECT R FROM (VALUES (1),(2),(3),(4)) n (R)) r

ON r.R BETWEEN 1 AND b.MaxRowNo

CROSS JOIN (SELECT C FROM (VALUES (1),(2),(3),(4)) n (C)) c

JOIN a ON a.PID = b.PID AND a.RowNo = 1 AND a.Rn = c.C

LEFT JOIN a a2 ON a2.PID = b.PID AND a2.RowNo = r.R AND a2.Rn = c.C

GROUP BY b.PID,r.R