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write OT note for PUJO find stone 8mm and Dj stent applied in short form like surgeon

OT NOTE
Date: 22/05/2026 Procedure: DJ Stenting + Stone Retrieval Surgeon: [Name] Anaesthesia: SAB / GA
Pre-op Dx: PUJO with right/left ureteric calculus 8mm
Post-op Dx: Same
Procedure:
Pt. positioned lithotomy. Parts painted & draped. Cystoscopy done — ureteric orifice identified. DJ stent 6Fr x 26cm railroaded over guidewire under C-arm guidance. Stent position confirmed — proximal coil in renal pelvis, distal coil in bladder. Stone 8mm noted at PUJ — fragmented / bypassed / pushed proximally. Adequate efflux noted. Cystoscope withdrawn. Urethral catheter (16Fr Foley) inserted & connected to drainage bag.
EBL: Minimal Complications: Nil Specimen: Stone fragments sent for analysis Drain: Urethral catheter in situ
Post-op orders:
  • IV fluids + antibiotics
  • Urine output monitoring
  • S/F after 48 hrs
  • ESWL / URS planned after 2–4 wks
  • DJ stent removal after 4–6 wks
Surgeon's signature: ___________

generate left PUJO ot note finding 8mm stone and applied dj stent securing haemotosis under spinal anesthesia like a surgeon

OT NOTE
Date: 22/05/2026 Time: _____ Surgeon: Dr. __________ Asst.: Dr. __________ Scrub Nurse: __________ Anaesthetist: Dr. __________ Anaesthesia: Spinal (SAB) — L3-L4, Inj. Bupivacaine 0.5% Heavy 3ml Position: Lithotomy
Pre-op Dx: Left PUJO with calculus 8mm
Post-op Dx: Left PUJO — 8mm calculus at PUJ, DJ stent in-situ
OPERATIVE FINDINGS:
  • 8mm calculus impacted at Left PUJ
  • Moderate hydroureteronephrosis proximal to stone
  • Mucosa — no active bleeding / growth
  • DJ stent successfully placed, position confirmed
PROCEDURE:
Pt. received in OT, shifted to OT table. SAB administered in sitting position at L3-L4 interspace — adequate level achieved. Pt. positioned in lithotomy, both lower limbs supported in stirrups. Perineum painted with Betadine & draped sterile.
Cystoscopy: 22Fr rigid cystoscope introduced per urethra under vision. Urethra, bladder neck, bladder wall, both ureteric orifices visualised. Left ureteric orifice identified — cone-shaped, normal position. Bladder mucosa unremarkable. No growth/calculus in bladder.
Guidewire Negotiation: 0.035" hydrophilic guidewire negotiated through left ureteric orifice under C-arm fluoroscopic guidance. Wire advanced proximally — mild resistance felt at PUJ level (level of calculus). Wire negotiated past the stone into renal pelvis — confirmed on C-arm.
DJ Stenting: 6Fr × 26cm DJ stent railroaded over guidewire under fluoroscopic guidance. Proximal coil confirmed in left renal pelvis, distal coil in bladder — position satisfactory on C-arm. Guidewire withdrawn. Good urine efflux noted through stent. Haemostasis secured — no active bleed.
Cystoscope withdrawn. 16Fr Foley catheter inserted per urethra, balloon inflated with 10ml NS, connected to urobag — clear urine noted.
EBL: Minimal (~5–10 ml) Complications: Nil intraoperative Specimen: Nil (stone not retrieved — in-situ, definitive Rx planned) Drain: Urethral catheter 16Fr in-situ
POST-OP INSTRUCTIONS:
  1. IV fluids — maintain adequate hydration
  2. Inj. Ceftriaxone 1g IV BD × 3 days
  3. Inj. Diclofenac 75mg IM SOS for pain
  4. Urine output monitoring Q2H
  5. Strict bed rest × 6 hrs post SAB
  6. Catheter removal after 24–48 hrs
  7. CECT KUB / USG review — OPD follow-up
  8. Plan: URS + Holmium Laser Lithotripsy / ESWL after 4 wks
  9. DJ stent removal after 4–6 wks
Surgeon's Signature: ________________
Date/Time: 22/05/2026 / _____

short form

OT NOTE | 22/05/2026
Pre-op Dx: Lt. PUJO + calculus 8mm Post-op Dx: Same Procedure: Cystoscopy + Lt. DJ stenting Surgeon: Dr.___ | Asst: Dr.___ Anaes: SAB L3-L4 | Position: Lithotomy
Findings:
  • 8mm calculus @ Lt. PUJ
  • Mod. hydronephrosis +++
  • Bladder — NAD
  • DJ stent in-situ, position ✓
Steps: Pt. in lithotomy. Parts painted & draped sterile. 22Fr cystoscope introduced PR urethra. Lt. ureteric orifice identified. 0.035" guidewire negotiated past PUJ calculus into renal pelvis under C-arm guidance. 6Fr × 26cm DJ stent railroaded over wire. Proximal coil — renal pelvis ✓, distal coil — bladder ✓ on C-arm. Urine efflux +. Haemostasis secured. Scope out. 16Fr Foley inserted.
EBL: Minimal | Complic.: Nil
Post-op:
  • IVF + Inj. Ceftriaxone 1g BD
  • Catheter out @ 24–48 hrs
  • Plan: URS/ESWL @ 4 wks
  • DJ stent removal @ 4–6 wks
Surgeon: _________
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