### WRITE UP 1

### HISTORY AND PHYSICAL  ### PNEUMONIA ###
SUBJECTIVE
**** is a *** year old male who is admitted to hospital for care of pneumonia. 
He has been ill for {NUMBERS 1-12:10} {TIME FRAME:9076} with symptoms of {RESPIRATORY SYMPTOMS:411}.
Past pulmonary history includes {RESPIRATORY HISTORY:412}.
OBJECTIVE
Appearance: {general appearance:5021}.
Lungs: {LUNG EXAM:401}.
Heart: {HEART EXAM:5510::"S1, S2 normal, no murmur, click, rub or gallop, regular rate and rhythm","brisk carotid upstroke without bruits","peripheral pulses very brisk","chest is clear without rales or wheezing","no pedal edema","no JVD","no hepatosplenomegaly":0}.
Abdomen: {PE ABDOMEN:5794}.
Chest Xray findings: infiltrate in {:5344}.
ASSESSMENT/PLAN
Patient has pneumonia and will be admitted for etiologic workup, intravenous fluids, antibiotics, and pulmonary toilet.  See orders.

### PRE-OP INSTRUCTIONS ###
1. No food or drink after midnight and before surgery. You may take your medications with sips of water as directed by your surgeon.
2. You may not drive if you have IV sedation or general anesthesia.
3. Make sure that you have the needed assistive device to protect yourself after surgery. Examples: wheelchair, walker, knee walker
4. Arrive at least one to two hours (as directed by your surgeon) pre-op for the procedure. Consult surgery site for details.
5. Mark the leg on which the surgery is to be performed with ink with the letters "YES."

### TEMPLATE ###
Subjective: **** is a *** year old male who has a chief complaint of a {WOUND TYPE:16206:::0} wound located on the {WOUND GENERAL BODY LOCATION:15914:::0}.
Dr. *** requested a consultation regarding the possible utility of *** for *** diagnosis of ***. 
Clinical Data        Data Pulled into Note
.allergy                 Allergies
.prob                         Problem List
.hprobl                 Hospital Problem List
.probcode                 Hospital Problems with ICD Codes
.vsranges                  Vital Signs Ranges Last 24 hrs *
.vs                         Last Vital Signs
.iobriefphp                 Intake Output Last 24 hrs (refreshable)
.bmi                         Body Mass Index
.bsa                         Body Surface Area
.socr                         Social History (refreshable)
.surgicalhxr                 Surgical History (refreshable)
.medicalhxr                 Medical History (refreshable)
       
Meds                         Data Pulled into Note
.actmed                 Meds the patient reported as taking
.medsip                 Currently Active Med Orders
.rrscheduled                 Scheduled Medications
.rriv                         IV Medications
.rrprn                         PRN Medications
.ptdischargemeds         Discharge Medication List
       
Patient Info                Data Pulled into Note
.id                         Patient Name, Age, and Sex
.name                         Patient's Name
.age                         Patient's Age
.dob                         Patient's Date of Birth
.dol                         Patient's Day(s) of Life
.los                         Patient's Length of Stay
.sex                         Patient's Sex
.mrn                         Medical Record Number
       
System Phrases         Statement
.bridge                 Bridge Note Template
.rba                         Risks, Benefits, and Alternatives
.scip                         SCIP Measures
.signattn                 Attending Statement
       
General        Data Pulled into Note
.sign        Your Name, License, Date, and Time
.me         Your Name
.td         Today's Date
.now         Current Time
       

*Available in Epic 2018 and later versions.

.abdpain

The patient presents with abdominal pain.  The patient is feeling better with a benign repeat examination.  I see nothing that would suggest an acute abdomen at this time.  Based on history, physical exam, risk factors, and tests; my suspicion for bowel obstruction, acute pancreatitis, intra abdominal abscess, perforated viscous, diverticulitis, cholecystitis, ischemic gut, AAA, cholangitis, pyelonephritis, appendicitis is very low and I feel the patient can be managed as an outpatient with follow up. Patient has been told that diagnosing the etiology of abdominal pain can be very challenging. Occasionally, abdominal complaints will change or previously negative tests will change and the patient may experience symptoms that they may feel are concerning. This may require the patient to return to the Emergency Department for further evaluation and treatment.  Instructions have been given for the patient to return to the ED for worsening of the pain, high fevers, in
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