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Left PUJ Calculus Management Report

The document details the medical case of a 57-year-old female patient, Sulaika U, who was admitted for left PUJ and renal calculi, undergoing surgery for left DJS removal and RIRS on July 14, 2025. Post-operative complications included vomiting and fever, which were managed conservatively, and she was discharged on July 17, 2025, with a prescription for antibiotics and follow-up advice. The patient is advised to return for a review in two weeks and to seek urgent care for any signs of infection or fever.

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Aadarsh Kavoram
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9 views2 pages

Left PUJ Calculus Management Report

The document details the medical case of a 57-year-old female patient, Sulaika U, who was admitted for left PUJ and renal calculi, undergoing surgery for left DJS removal and RIRS on July 14, 2025. Post-operative complications included vomiting and fever, which were managed conservatively, and she was discharged on July 17, 2025, with a prescription for antibiotics and follow-up advice. The patient is advised to return for a review in two weeks and to seek urgent care for any signs of infection or fever.

Uploaded by

Aadarsh Kavoram
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

DEPARTMENT OF UROLOGY

Patient Name: SULAIKA U Age/Sex: 57 Y 2 M IP No:- IP2025/018754 Ward/Bed No: IKC


10 D / Female OP No:- IQ2025/038676 - OT GENERAL /
4

Address: ULUVAYIL Date of Admission: 14/07/2025 10:02 AM


Date of Discharge: 17/07/2025
Consultant Doctor: Dr. THAHA RASHID P.T. ICD Code:-
Final Diagnosis: Co morbidities:
 Left PUJ calculus  Type 2 DM
 Left renal calculi  DLP
 S/P:Left DJS - 01/07/2025
Surgery: Left DJS removal +RIRS+DJS. Date of Surgery:14/07/2025
Chief Complaints : Left sided colic
On Examination :Abdomen soft and NAD
Investigation Findings:
CT KUB (NON CONTRAST) 09/JUL/2025 (OUTSIDE)
 Imaging features suggestive of left renal subcapsular hematoma. Left DJ stent noted insitu.
 Left renal calculi as described
Two hyperdense calculi (mean HU 541 )noted in the renal pelvis, largest measuring ~ 10 x 9 mm.
Two hyperdense calculi measuring ~ 12 x 9 mm (mean HU 390 )and 5.5 x 3.1 mm(mean HU 400) noted in the
lower pole and mid pole calyx respectively.
Details of Cross Consultations:
Department of Anesthesia
Department of General Medicine ([Link])
Surgery /Procedure Done:
Left DJS removal + RIRS+DJS done under GA
Left DJS removed.
Left ureteroscopy done GW placed.
Sheath inserted over GW
Scope introduced into kidney
Left PUJ calculus
Left renal calyceal calculi
Calculi completely fragmented with laser
Left DJS (6Fr) re inserted.
PUC+
Course in the Hospital:
Post operative period patient had vomiting and fever,managed conservatively
General medicine consultation was sought for the same and their orders were followed
CBD removed on 1st post operative day
Now patient condition better,fever reduced,hence discharged with IV antibiotics.
Medication administered during the hospital stay:IV antibiotics and other supportive measures.
Condition at the Time of Discharge:Afebrile, better
Discharge Medication and Follow up Advices:
1. [Link] 1.5 GM 1-0-1 x 3 DAYS F/B
[Link] 500 MG 1-0-1 x 5 DAYS
2. [Link] 650 MG 1-1-1 x 3 DAYS F/B SOS
3. [Link] 40 MG 1-0-0 x 5 DAYS
4. [Link] 0.4 MG 0-0-1 x 2 WEEKS
5. [Link] 5 MG 0-0-1 x 4 DAYS
Regular Medication:
1. [Link] 500 MG 1-0-0 x
2. [Link] 5 MG 1-0-1 x CONTINUE
3. [Link] 10 MG 0-0-1 x
Review after 2 weeks in UROLOGY OPD.
When to obtain urgent care:Infection and fever.
[SIGNATURE]
Attending Consultant : [Link] RASHID P.T. MS,Mch(URO)

 കിഡ്‌നിയുടെ ഉള്ളിൽ ഒരു ട്യൂബ് (DJ STENT) ഇട്ടിട്ടുണ്ട്.

 ട്യൂബ് 3 ആഴ്ച്ച കഴിഞ്ഞു എടുക്കേണ്ടതാണ് UNDER LA.

Patient’s Signature

(OP booking No: 0495 2379201 Booking Time: 7.00AM-7.00 PM)

For Home Health Care Services Contact: 7902 678 678, 7902 679 679

In case of any emergency, Please contact 9744064446, 0495-2379115/114/317


Patient Name: SULAIKA U
IP No:- IP2025/018754
Address: ULUVAYIL
OP No:- IQ2025/038676
Consultant Doctor: Dr. THAHA RASHID P.T.

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