AUR ER note

· 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.