AUR ER note 편집하기

{| class="wikitable"
|· '''C.C''': onset, recent onset 
· '''P.I''': 환자 평소 (과거력 있던 자, 건강했던 자)로 소변보

지 못하고 있다가 자신의 의지로 소변 볼 수 없어 이를 

주소로 본원 ER내원 '''(Alcohol Hx, URI med Hx)''' 

· '''PHx''': Hepatitis/HTN/DM/Tbc (///) OP Hx 

GU Hx ( 1. '''BPH Dx & med'''- 2. head, neck, back

trauma Hx & CVA Hx ) 

· '''ROS''': A/N/V/C/D (////), F/ (/) 

urinary Sx: frequency (1번/시간), 

Nocturia ( 번/1night) 

dysuria (-/+), tenesmus (-/+), hesitency (-/+), 

urgency (-/+) 

weak stream (-/+), decreased urine volume (-/+) 

그 외 특이 Sx: 

· '''P/Ex''': Vital, Mental, General condition 

Head & Neck: anemic, icteric, soft neck 

Chest: Heart, lung sound 

Abdomen: Bowel Sound, abd scar, 

abd T/RT (/), CVAT (/) 

Extrimities: pitting edema, grossly free 

'''DRE''': 

· '''ER Order''': 

1. fluid none, Foley insertion & check residual urine. 

2. routine Lab. (CBC, B/Cr, elctrolyte, U/A with

microscopy, KUB) 

3. GU Lab. (PSA, urine GS, urine culture, urine AFB) 

4. prn (if fever>37.8 → blood culture, fluid 30GTT, 

AAP2T) 

· '''Lab'''.: 

1. check residual urine volume

2. X-ray: KUB. 

3. urine study: U/A with microscopy 

4. serum study: BUN/Cr, CBC, elctrolyte`

· '''Plan & recommend''' 

1. D/C c medication 

Foley insertion state로 퇴원 조치 할 것 (Foley 

dressing 한 상태로...). 

(Cravit 3T/#3, Beszyme 3T/#3, Soleton 3T/#3) *

7days 

2. GU OPD F/U.
|}