Detailed Treatment Process
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Male, 48 years old Discharge Summary Department: Urology Admission Date: September 5 Discharge Date: October 8 Outpatient Diagnosis: Renal colic; left ureteral stone?; bilateral renal stones Admission Diagnosis: Renal colic; left ureteral stone?; bilateral renal stones Discharge Diagnosis: Left ureteral stricture; bilateral renal stones Main symptoms and signs on admission: “Paroxysmal left flank and back pain for 2 days.” Physical examination: Alert, mild fatigue, active position, walked into the ward, cooperative with examination, heart and lungs unremarkable. No tenderness in the bladder area or along the course of either ureter. Positive percussion tenderness over the left kidney. No urethral stricture. Digital rectal examination: Prostate enlarged to grade I, smooth surface, shallow central sulcus, no blood on glove. Both testes and epididymides normal on palpation, no tenderness. Main laboratory results: Renal function: Urea 7.9 mmol/L, creatinine 137 umol/L; Electrolytes: Bicarbonate 20 mmol/L. Complete blood count: White blood cells 14.81 × 10⁹/L, neutrophils 85.61%. Urinalysis: White blood cells 8-10/HP, red blood cells 2-3/HP. Liver function, blood glucose, and coagulation profile all normal. Special investigations and consultations: Chest X-ray: Left pleural thickening. ECG normal. Contrast-enhanced CT: Stone in the upper left ureter. Postoperative KUB: Double J stent in the left ureter in proper position. Course and treatment outcome: After admission, all examinations were completed. Anti-inflammatory and antispasmodic treatment was given. Based on the findings, left ureteral stone was suspected. Preoperative preparation was completed, and on September 13, under general anesthesia, left ureteroscopy was performed. Intraoperatively, stricture was noted in the mid-to-lower left ureter. The ureteroscope could not pass smoothly. A F7 double J stent was placed. On September 20, left ureteroscopy was repeated under general anesthesia. No stone was seen in the left ureter. The stricture remained obvious. On September 26, under general anesthesia, incision of the left ureteral stricture was performed. The operation went smoothly. The patient recovered well postoperatively with no significant discomfort and was discharged. Complications: None Main symptoms and signs at discharge: Normal urination, no obvious discomfort, good wound healing. Discharge medications and advice: 1. Rest as appropriate; 2. Removal of the double J stent via outpatient cystoscopy in 8 weeks. 3. Medications: Cefaclor 4 boxes, terazosin 2 boxes. Treatment outcome: Cured
Eight weeks later, the patient returned for outpatient follow-up. The following is the laboratory report from that visit: Laboratory Report Department: Urology Patient Type: Outpatient Specimen Type: Urine Collection Date: December 5 Analysis Item Result Reference Range Color Yellow Vitamin C Negative (Negative) Nitrite Negative (Negative) Occult blood +++ (Negative) Leukocyte esterase + (Negative) Red blood cells (quantitative) 1,815.36 ↑ (0-5 /ul) White blood cells (quantitative) 46.20 ↑ (0-9 /ul) Uric acid crystals 0.00 (0-6) Non-squamous epithelial cells 0.66 (0-2) Squamous epithelial cells 1.32 (0-5) Clarity Clear Glucose Normal (Negative (-)) Bilirubin Negative (Negative) Ketones Negative (Negative) Specific gravity 1.020 (1.005-1.030) pH 6 (5-9) Urine protein + (Negative) Urobilinogen Normal (Normal) Examination Period: December 5 Report Date: December 5
* Two days later, the double J stent was successfully removed under cystoscopy. The outpatient record noted that the procedure went smoothly, with written instructions for outpatient follow-up, but without specifying a time frame. Unless otherwise indicated, all subsequent medical record dates refer to the following year.
Ultrasound Report Department: Outpatient/Emergency Clinical Diagnosis: To be determined Examined Area: Kidneys, ureters, post-void residual Examination Date: September 11 Ultrasound Description: Organ sections observed (√ observed, × not observed, - unclear) Left kidney: Coronal (√) \ Sagittal (√) \ Transverse (√) \ Craniocaudal 100 mm \ Transverse diameter 45 mm Right kidney: Coronal (√) \ Sagittal (√) \ Transverse (√) \ Craniocaudal 106 mm \ Transverse diameter 54 mm Left ureter: Upper segment (-) \ Lower segment (-) \ Intramural segment (-) \ Dilation in upper segment \ Diameter 10 mm Right ureter: Upper segment (-) \ Lower segment (-) \ Intramural segment (-) \ Dilation in - segment \ Diameter - mm Left kidney normal morphology, smooth capsule, collecting system separation 27 mm, no obvious abnormal echoes. Right kidney normal morphology, smooth capsule, no collecting system separation, no obvious abnormal echoes. Left ureter dilated, mid-to-lower segment not clearly visualized. Right ureter normal diameter, no abnormal echoes or space-occupying lesions. Post-void residual: 16 ml Ultrasound Impression: Moderate left hydronephrosis Dilation of upper left ureter Post-void residual: 16 ml Report Date: September 11 11:09:24
Urinalysis Report Department: Urology Patient Type: Outpatient Specimen Type: Urine Collection Date: September 11 Clinical Diagnosis: Color Yellow Clarity Clear Glucose Negative (Negative (-)) Bilirubin Negative (Negative (-)) Ketones Negative (Negative (-)) Specific gravity <=1.005 ↓ (1.003-1.03) pH 6.0 (5.4-8.4) Protein Negative (Negative (-)) Urobilinogen 3.2 (3-16 umol/L) Nitrite Negative (Negative (-)) Occult blood Negative (Negative (-)) Leukocytes Negative (Negative (-)) Microscopic RBC 0 (0-3 /HP) Microscopic WBC 0 (0-5 /HP) Examination Date: September 11 Report Date: September 11
SPECT/CT Report Examination Date: September 19 Imaging Findings: Left kidney poorly visualized; right kidney clearly visualized GFR Values: Left kidney: 10.75 ml/min Right kidney: 40.44 ml/min Impression: Severely reduced left kidney GFR; right kidney GFR essentially normal Report Date: September 19
Admission Record History provided by: Patient Reliability: Reliable Admission Time: September 24 09:08 Record Time: September 24 09:38 Chief Complaint: One year after surgery for left ureteral stricture. History of Present Illness The patient was admitted to our department last year in September for “left flank and back pain.” After completing ureteroscopy and other examinations, left ureteral stricture was diagnosed. Surgery was performed under general anesthesia on September 26 of last year and went smoothly. In the past two weeks, the patient developed aching discomfort in the left flank and back. He presented to our hospital, where examinations suggested “left hydronephrosis.” Recurrent stricture was considered. The patient requested admission for further active treatment. He was therefore admitted with the outpatient diagnosis of “left hydronephrosis, recurrent left ureteral stricture.” Further history revealed a 40-year history of right renal stones. Sleep fair, normal spirits, fair appetite, normal bowel and bladder function, no significant weight loss. Past History Surgical/trauma history: Left ureteral stricture surgery one year ago. Denies other major surgery or trauma. Physical Examination T: 36.5℃ P: 80/min R: 18/min BP: 110/70 mmHg General condition: Walked into the ward, alert, normal development and nutrition, no acute distress, cooperative with examination. Old surgical scar noted on the left flank and back.
Discharge Summary Department: Urology Admission Date: September 24 Discharge Date: November 2 Outpatient Diagnosis: Left hydronephrosis; recurrent left ureteral stricture Admission Diagnosis: Left hydronephrosis; recurrent left ureteral stricture; left renal insufficiency Discharge Diagnosis: Left hydronephrosis; recurrent left ureteral stricture; left renal insufficiency Main symptoms and signs on admission: “One year after left ureteral stricture surgery.” Admitted. Physical examination: Alert, no jaundice of skin or mucosa, no superficial lymphadenopathy. Soft abdomen with old surgical scar on left flank and back. No bladder tenderness, no tenderness along either ureter. No percussion tenderness over either kidney. No urethral stricture. Both testes and epididymides normal. Digital rectal examination normal. Main laboratory results: Blood and urine routine, liver function, electrolytes, and coagulation profile normal. Renal function: Creatinine 136 umol/L. Tumor markers: CA211 4.82 ng/ml. Urine acid-fast bacilli: Negative. Special investigations and consultations: Chest X-ray: No active lesions in either lung. ECG: Sinus rhythm. Antegrade ureterography: Narrowing of the upper left ureter, significance to be determined. Course and treatment outcome: After admission, ureteroscopy and antegrade ureterography were completed. Diagnosis was stricture at the upper left ureter and ureteral orifice. Severe left hydronephrosis with impaired left renal function. Left percutaneous nephrostomy was performed, draining approximately 180 ml of urine per day. Further surgery was planned. Complications: None Main symptoms and signs at discharge: General condition stable, alert, normal temperature, stable vital signs, fair appetite and sleep. Able to void spontaneously with clear urine. No specific complaints. Left nephrostomy tube draining well, approximately 180 ml of clear urine in 24 hours. Nephrostomy site clean with no exudate. Discharge medications and advice: 1. Rest and increase fluid intake. 2. Outpatient follow-up. Elective surgery to be arranged. Treatment outcome: Improved
Discharge Record Department: Urology Admission Date: November 12 Discharge Date: December 4 Admission Diagnosis: 1. Left hydronephrosis, non-functioning left kidney; 2. Status post left ureteral incision Discharge Diagnosis: 1. Left hydronephrosis, non-functioning left kidney; 2. Status post left ureteral incision Main symptoms and signs on admission: One year after left ureteral stricture incision, routine examination revealed left hydronephrosis for one month. No redness or swelling in either kidney area, no palpable kidneys, no tenderness or percussion tenderness over either kidney, no vascular bruits. No tenderness or rebound along either ureteral projection. No suprapubic bladder distension or tenderness; suprapubic percussion showed no bladder fullness. Normal penile development; both testes and epididymides normal without enlargement, tenderness, or nodules. Spermatic cords normal. Main laboratory results and examinations: Abdominal CT plain and contrast (September 17, outside hospital) showed inflammatory stricture of the upper left ureter with severe hydronephrosis and hydroureter. Markedly reduced left renal perfusion and excretory function. Small stone in the lower pole of the right kidney. Treatment course: The patient was admitted for “one year after left ureteral stricture incision with left hydronephrosis discovered on examination one month ago.” After completing admission workup, laparoscopic left nephrectomy for non-functioning kidney was performed on November 15. The procedure went smoothly under satisfactory anesthesia with no transfusion. Postoperatively, anti-infective, hemostatic, and fluid therapy were given. On postoperative day 4, chyle leak was noted from the wound drain. After drainage management, the chylous output decreased daily. The patient recovered well and the drain was removed. Condition at discharge: Good general status, no fever or abdominal pain. Urinary catheter and drain removed. Wound healing satisfactory. Discharge instructions: 1. Regular outpatient follow-up with close monitoring of right kidney and ureteral function. 2. Continue low-fat diet for one week after discharge. 3. Rest and moderate exercise.
The final treatment outcome was surgical removal of the non-functioning left kidney. Subsequently, on the recommendation of the medical damage appraisal committee, the hospital provided financial compensation to the patient.