Urinary stone ER note

· C.C: onset, recent onset, pain nature, radiation, attack Hx. · P.I: 환자 평소 (과거력 있던 자, 건강했던 자)로 부터 (갑자기, 서서히) develop된 (어느 부위) pain을 주소로 본원 ER내원. · PMHx: Hepatitis/HTN/DM/Tbc ( /// ) OP Hx Stone Hx ( ) · ROS: A/N/V/C/D ( //// ), F/C ( / ) · urinary Sx: frequency (1번/ 시간), nocturia ( 번/1 night) · dysuria (-/+), tenesmus (-/+), hematuria (-/+), weak stream (-/+), decreased urine volume (-/+) 그외 특이 Sx: · P/Ex: Vital (fever), Mental, General condition Head & Neck: anemic, icteric, soft neck Chest: Heart, lung sound Abdomen: Bowel Sound, abd scar, abd T/RT ( /) appendicitis 와의 감별에 유의, CVAT ( /) Extrimities: pitting edema, grossly free. · ER Order: 1. fluid 30GTT (환자 pain심하면 spamon 2@ 섞어 주세요.) 2. routine Lab. (CBC, B/Cr, elctrolyte, U/A with microscopy ) 3. routine X-ray (Chest PA, KUB, erect Abd.) 4. prn Lab. (if fever>37.8 → urine GS, urine culture, urine AFB) 5. prn inj. (if pain → Tarasyn 1@/#od IM). If, pregnant women, Demerol 25mg/IM · Lab.: 1. X-ray: KUB- level 에서 stone 보임. CXR- pleural effusion (-/+) 2. urine study: U/A with microscopy ( RBC: ,WBC: ) 3. serum study: BUN/Cr, CBC · Plan & recommend 1. non-enhanced CT with KUB (병원마다 다름) 2. Discharge medication 필요시 항생제 항진경제, 진통제는 섞어줄지, prn으로 할 지 결정