Make a case summary of a case of ureteric calculi who underwent ursl on 13.06.2026

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Here is a standard clinical case summary for a fictional patient with ureteric calculi who underwent Ureteroscopic Lithotripsy (URSL):

CASE SUMMARY

Department of Urology Date of Preparation: 14.07.2026

PATIENT IDENTIFICATION

Field	Details
Name	Mr. Rajesh Kumar (fictional)
Age / Sex	42 years / Male
IP No.	UL-2026-0613
Ward	Urology Ward, Bed No. 12
Date of Admission	11.06.2026
Date of Surgery	13.06.2026
Date of Discharge	15.06.2026
Consultant	Dr. [Name], MS, MCh (Urology)

CHIEF COMPLAINTS

Severe right flank pain radiating to the groin - 5 days duration
Intermittent gross hematuria - 3 days duration
Nausea and vomiting - 3 days duration
Dysuria - 2 days duration

HISTORY OF PRESENT ILLNESS

Mr. Rajesh Kumar, a 42-year-old male, presented to the urology OPD on 11.06.2026 with a 5-day history of sudden-onset, severe, colicky right flank pain radiating to the right groin and inner thigh. The pain was 8/10 in severity, paroxysmal in nature, and was associated with restlessness, nausea, and two episodes of vomiting. He also noted intermittent passage of blood-tinged urine over the past 3 days and burning micturition for 2 days. There was no fever, no urinary retention, and no prior history of similar episodes.

He denied any recent trauma, and there was no history of prolonged immobilization or high-protein diet.

PAST MEDICAL & SURGICAL HISTORY

No prior history of urolithiasis
No known diabetes mellitus, hypertension, or chronic kidney disease
No prior abdominal or urological surgeries
No known drug allergies

PERSONAL & SOCIAL HISTORY

Non-smoker, occasional alcohol consumer
Sedentary occupation (software professional)
Low daily fluid intake (estimated < 1.5 L/day)
Diet: mixed, with high animal protein and oxalate-rich foods

FAMILY HISTORY

Father had history of renal calculi (managed conservatively)

GENERAL EXAMINATION

Conscious, oriented, and cooperative
Mild distress due to pain
Afebrile; Temperature: 37.1°C
Pulse: 92 bpm, regular
Blood Pressure: 126/80 mmHg
SpO2: 99% on room air
No pallor, icterus, cyanosis, or lymphadenopathy

SYSTEMIC EXAMINATION

Abdomen:

Soft, non-distended
Right renal angle (CVA) tenderness: present and marked
No guarding or rigidity
Bowel sounds: normal

Other systems: Unremarkable

INVESTIGATIONS

Laboratory

Investigation	Result	Reference Range
Hemoglobin	13.8 g/dL	13-17 g/dL
TLC	9,200 cells/µL	4,000-11,000
Platelet Count	2.1 lakh/µL	1.5-4.5 lakh/µL
Blood Urea	28 mg/dL	15-40 mg/dL
Serum Creatinine	1.1 mg/dL	0.7-1.2 mg/dL
Serum Uric Acid	7.2 mg/dL	3.5-7.2 mg/dL
Serum Calcium	9.4 mg/dL	8.5-10.5 mg/dL
Urine R/E	RBCs: 30-40/hpf, WBCs: 8-10/hpf, Proteins: trace	-
Urine Culture	Sterile	-
PT/INR	1.0	-
Blood Group	O Positive	-

Imaging

Ultrasound Abdomen & Pelvis (11.06.2026):

Right hydroureteronephrosis (mild-to-moderate grade)
Echogenic focus at right vesicoureteric junction (VUJ) suggestive of calculus (~9 mm)
Left kidney and ureter: normal
Urinary bladder: normal

NCCT KUB (Non-Contrast CT KUB) (11.06.2026):

Right ureteric calculus at the right VUJ measuring 9 x 7 mm, density ~1,050 HU
Mild proximal right hydroureteronephrosis
No calculi in left system or bladder
No perinephric fat stranding
Impression: Right VUJ calculus with mild right hydroureteronephrosis - Ureteroscopic intervention advised

DIAGNOSIS

Primary Diagnosis: Right vesicoureteric junction (VUJ) calculus - 9 mm

Secondary: Mild right hydroureteronephrosis

PRE-OPERATIVE PREPARATION

Informed written consent obtained from patient
Pre-anesthesia fitness: Grade I (ASA-I)
Anesthesia planned: Spinal anesthesia
Antibiotic prophylaxis: Injection Ceftriaxone 1g IV, given 30 minutes prior to surgery
Nil by mouth: 6 hours prior to surgery
Parts prepared and draped
IV access secured; IV fluids started

OPERATIVE PROCEDURE

Date: 13.06.2026 Procedure: Ureteroscopic Lithotripsy (URSL) - Right Side Surgeon: Dr. [Name], MCh Urology Anesthesia: Spinal anesthesia Position: Lithotomy Duration: 45 minutes

Intraoperative Findings:

Cystoscopy performed - ureteric orifice identified
Semi-rigid ureteroscope (8.5 Fr) introduced into right ureter under fluoroscopic guidance
Calculus located at right VUJ - single, impacted, approximately 9 mm
Ureteroscope advanced up to the calculus
Holmium:YAG laser lithotripsy performed (settings: 0.8 J × 15 Hz) - calculus fragmented into fine dust and small passable fragments
Complete fragmentation achieved; no residual fragment > 2 mm
Ureteric mucosa intact; no perforation; no significant bleeding
DJ stent (Double-J stent, 6 Fr, 26 cm) placed right side under fluoroscopic guidance
Ureteroscope withdrawn; procedure completed uneventfully

POST-OPERATIVE COURSE

Immediate Post-op (Day 0 - 13.06.2026):

Shifted to recovery room; vitals stable
Adequate analgesia provided (Inj. Diclofenac 75 mg IV SOS)
IV fluids continued; urine output monitored - adequate (>1 mL/kg/hr)
Gross hematuria noted - expected, cleared by evening

Day 1 (14.06.2026):

Patient comfortable; flank pain significantly reduced
Mild lower urinary tract symptoms (LUTS) attributed to DJ stent - managed with alpha-blocker (Tab. Tamsulosin 0.4 mg OD)
Diet: Normal diet resumed
Vitals stable throughout
Urine output: adequate, mild hematuria

Day 2 (15.06.2026) - Discharge Day:

Patient ambulatory and comfortable
No fever; no significant hematuria
Discharged in stable condition

DISCHARGE MEDICATIONS

Tab. Tamsulosin 0.4 mg - once daily (for DJ stent symptoms)
Tab. Lornoxicam 8 mg - twice daily x 5 days (analgesic)
Tab. Nitrofurantoin 100 mg - twice daily x 7 days (prophylactic antibiotic)
Tab. K-Cit (Potassium Citrate) 1080 mg - thrice daily (urinary alkalinizer, to prevent recurrence)
Adequate hydration advised: > 3 L of fluids per day

ADVICE ON DISCHARGE

Increase daily fluid intake to maintain urine output > 2 L/day
Avoid oxalate-rich foods (spinach, nuts, chocolate, tea)
Reduce animal protein and salt intake
Follow-up after 4 weeks for DJ stent removal (Cystoscopic stent removal planned: 13.07.2026)
X-Ray KUB or USG at follow-up to confirm stone clearance
Metabolic workup (24-hour urine oxalate, calcium, citrate) to be done at 6-week follow-up

HISTOPATHOLOGY / STONE ANALYSIS

Stone fragments sent for chemical analysis
Result (pending at discharge): Calcium oxalate monohydrate (Whewellite) - [to be updated]

FOLLOW-UP PLAN

Date	Plan
13.07.2026	DJ stent removal (cystoscopic); USG KUB; review stone analysis report
3 months post-op	Repeat NCCT KUB to confirm stone-free status; metabolic evaluation
6 months	Recurrence risk stratification and dietary counseling

SUMMARY

Mr. Rajesh Kumar, a 42-year-old male, presented with right ureteric colic secondary to a 9 mm right VUJ calculus confirmed on NCCT KUB. He underwent elective Ureteroscopic Lithotripsy (URSL) with Holmium:YAG laser on 13.06.2026, which was performed uneventfully under spinal anesthesia. Complete stone fragmentation was achieved and a DJ stent was placed. Post-operatively, the patient was stable and was discharged on day 2 with a DJ stent in situ, analgesics, and lifestyle modification advice. DJ stent removal is planned on 13.07.2026. He is advised metabolic workup and long-term dietary modification for recurrence prevention.

Prepared by: Dr. [Resident Name], Junior Resident, Dept. of Urology Verified by: Dr. [Consultant Name], MS, MCh Urology Date: 14.07.2026

Note: All patient details above are fictional/template. Replace bracketed fields and placeholder values with actual patient data before use in any official or medico-legal context.

Make a continuous case summary

Here is the same case written as a continuous prose narrative, as used in clinical case presentations and academic records:

CASE SUMMARY

Department of Urology | IP No.: UL-2026-0613 | Date: 14.07.2026

Mr. Rajesh Kumar, a 42-year-old male software professional, was admitted to the Urology ward on 11.06.2026 with a 5-day history of sudden-onset, severe, colicky right flank pain radiating to the right groin and inner thigh, associated with nausea, two episodes of vomiting, intermittent gross hematuria of 3 days duration, and dysuria of 2 days duration. The pain was paroxysmal, 8/10 in severity, and was not relieved by change of position. There was no history of fever, urinary retention, or prior similar episodes. He is a known sedentary individual with habitually low fluid intake (less than 1.5 litres per day) and a diet rich in animal protein and oxalate-containing foods. His father had a history of renal calculi managed conservatively. There was no history of diabetes mellitus, hypertension, chronic kidney disease, prior urological surgery, or known drug allergies.

On general examination, the patient was conscious, oriented, and in mild distress due to pain. He was afebrile (37.1°C), with a pulse of 92 beats per minute, blood pressure of 126/80 mmHg, and SpO2 of 99% on room air. Abdominal examination revealed marked right costovertebral angle tenderness. The abdomen was soft with no guarding, rigidity, or organomegaly. All other systemic examinations were within normal limits.

Laboratory investigations revealed a hemoglobin of 13.8 g/dL, total leucocyte count of 9,200 cells/µL, serum creatinine of 1.1 mg/dL, blood urea of 28 mg/dL, serum calcium of 9.4 mg/dL, and serum uric acid of 7.2 mg/dL - all within acceptable limits. Urine routine examination showed 30-40 red blood cells per high power field with 8-10 white blood cells per high power field and a trace of protein. Urine culture was sterile. Coagulation profile was normal (INR 1.0).

Ultrasound abdomen performed on 11.06.2026 demonstrated mild-to-moderate right hydroureteronephrosis with an echogenic focus at the right vesicoureteric junction (VUJ), suggestive of a calculus of approximately 9 mm. The left kidney, ureter, and urinary bladder were normal. A subsequent non-contrast CT KUB (NCCT KUB) on the same day confirmed a right VUJ calculus measuring 9 x 7 mm with a Hounsfield unit density of approximately 1,050 HU, associated with mild proximal right hydroureteronephrosis and no perinephric fat stranding. No calculi were identified in the contralateral system or urinary bladder.

Based on clinical presentation, imaging findings, and failure of spontaneous passage given the calculus size and location, a decision was made to proceed with elective Ureteroscopic Lithotripsy (URSL) of the right side. Informed written consent was obtained, pre-anesthetic fitness was assessed as ASA Grade I, and the patient was kept nil by mouth for 6 hours prior to surgery. Antibiotic prophylaxis was administered in the form of injection Ceftriaxone 1 g intravenously 30 minutes before the procedure.

The procedure was performed on 13.06.2026 under spinal anesthesia with the patient in the lithotomy position. Cystoscopy was performed and the right ureteric orifice was identified. A semi-rigid ureteroscope (8.5 Fr) was introduced into the right ureter under fluoroscopic guidance. The calculus was located at the right VUJ - single, impacted, measuring approximately 9 mm. Holmium:YAG laser lithotripsy was performed at settings of 0.8 J x 15 Hz, resulting in complete fragmentation of the calculus into fine dust and small passable fragments with no residual fragment greater than 2 mm. The ureteric mucosa was intact throughout with no evidence of perforation or significant bleeding. A 6 Fr, 26 cm Double-J (DJ) stent was placed in the right ureter under fluoroscopic guidance at the end of the procedure. The total operative time was approximately 45 minutes, and the procedure was completed uneventfully.

In the immediate post-operative period, the patient was shifted to the recovery room with stable vitals. Adequate analgesia was provided with injection Diclofenac 75 mg IV as needed. Intravenous fluids were continued and urine output remained adequate throughout, exceeding 1 mL/kg/hour. Gross hematuria was noted in the immediate post-operative period, which cleared by the evening of the same day. On the first post-operative day (14.06.2026), the patient was comfortable with a significant reduction in flank pain. Mild lower urinary tract symptoms (LUTS) in the form of frequency and urgency were attributed to the indwelling DJ stent and were managed with Tab. Tamsulosin 0.4 mg once daily. Diet was resumed as normal and vitals remained stable. By the second post-operative day (15.06.2026), the patient was ambulatory, comfortable, afebrile, with no significant hematuria, and was discharged in stable condition with the DJ stent in situ.

On discharge, the patient was prescribed Tab. Tamsulosin 0.4 mg once daily for DJ stent-related LUTS, Tab. Lornoxicam 8 mg twice daily for 5 days as an analgesic, Tab. Nitrofurantoin 100 mg twice daily for 7 days as prophylactic antibiotic cover, and Tab. Potassium Citrate (K-Cit) 1080 mg thrice daily as a urinary alkalinizer for recurrence prevention. He was advised to maintain a fluid intake of more than 3 litres per day, restrict dietary oxalate (spinach, nuts, chocolate, tea) and animal protein, and reduce sodium intake. Stone fragments retrieved intraoperatively were sent for chemical analysis; results were pending at the time of discharge.

The patient has been scheduled for follow-up on 13.07.2026 for cystoscopic DJ stent removal along with an ultrasound KUB to confirm stone-free status and review of the stone analysis report. A metabolic evaluation including 24-hour urine oxalate, calcium, and citrate estimation is planned at the 6-week follow-up, and a repeat NCCT KUB is planned at 3 months to confirm complete stone clearance and guide long-term recurrence prevention strategies.

Prepared by: Dr. [Resident Name], Junior Resident, Department of Urology Verified by: Dr. [Consultant Name], MS, MCh Urology Date: 14.07.2026

Note: All patient details are fictional/template. Replace bracketed fields with actual patient data before use in any official or medico-legal document.

Concise

CASE SUMMARY

Dept. of Urology | IP No.: UL-2026-0613 | Date: 14.07.2026

Mr. Rajesh Kumar, a 42-year-old male, presented on 11.06.2026 with a 5-day history of right flank pain radiating to the groin, gross hematuria, nausea, vomiting, and dysuria. He had no prior urological history, was habitually sedentary with low fluid intake, and had a family history of renal calculi. General examination revealed mild distress with marked right costovertebral angle tenderness. Vitals were stable and all systemic examinations were unremarkable.

Investigations showed a serum creatinine of 1.1 mg/dL, sterile urine culture with microscopic hematuria, and a normal coagulation profile. NCCT KUB confirmed a right VUJ calculus measuring 9 x 7 mm (1,050 HU) with mild right hydroureteronephrosis.

In view of the calculus size and failure of spontaneous passage, Ureteroscopic Lithotripsy (URSL) was planned. The procedure was performed on 13.06.2026 under spinal anesthesia in the lithotomy position. Semi-rigid ureteroscopy (8.5 Fr) was performed and the impacted right VUJ calculus was fragmented completely using Holmium:YAG laser lithotripsy (0.8 J x 15 Hz). No mucosal injury or perforation was noted. A 6 Fr DJ stent was placed at the end of the procedure. Total operative time was 45 minutes and the procedure was uneventful.

Post-operatively, the patient had an uncomplicated recovery. Hematuria cleared by day 0 evening. Mild stent-related LUTS on day 1 were managed with Tamsulosin. He was discharged on day 2 (15.06.2026) in stable condition on Tamsulosin, analgesics, antibiotics, and potassium citrate, with advice on high fluid intake and dietary modification.

Stone fragments were sent for analysis. DJ stent removal is scheduled on 13.07.2026, followed by metabolic evaluation and repeat imaging at 3 months.

Dr. [Resident] | Verified by Dr. [Consultant], MCh Urology | 14.07.2026

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