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### 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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### 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
{Extra lines not shown}

@[email protected]

@[email protected]

@[email protected]
@[email protected]
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Result - Copy and paste this output: