Calculus of kidney Stricture or kinking of ureter Other acute postoperative pain Lumbago
 
Name:  ___                  ___ No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: UROLOGY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Left renal stone
 
Major Surgical or Invasive Procedure:
ESWL, left ureteral stent placement

 
History of Present Illness:
___ with 1.5cm L UPJ stone.
 
Past Medical History:
lower back pain
 
Social History:
___
Family History:
non-contributory
 
Brief Hospital Course:
The patient was admitted to the Urology service after undergoing 
ESWL and left ureteral stent placement.  His pain was controlled 
with oral pain medications.  He was tolerating a regular diet. 
He was ambulating without assistance, and voiding without 
difficulty. He is given explicit instructions to call Dr. ___ 
___ follow-up.

 
Medications on Admission:
None
 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain, fever.  
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 
hours) as needed for pain.  
3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 
hours) as needed for pain.  
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
5. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 
times a day) as needed for bladder spasm.  
6. phenazopyridine 100 mg Tablet Sig: Two (2) Tablet PO TID (3 
times a day) for 3 days.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Left renal stone

 
Discharge Condition:
Stable
A+OX3
ambulates independently

 
Discharge Instructions:
-No vigorous physical activity for 2 weeks. 

-Expect to see occasional blood in your urine and to experience 
urgency and frequecy over the next month.

-You may have already passed your kidney stone, or it may still 
be in the process of passing.  You may experience some pain 
associated with spasm of your ureter.  This is normal.  Take 
Motrin as directed and take the narcotic pain medication as 
prescribed if additional pain relief is needed.   

-Tylenol should be your first line pain medication, a narcotic 
pain medication has been prescribed for breakthough pain >4.  
Replace Tylenol with narcotic pain medication.  Max daily 
Tylenol dose is 4gm, note that narcotic pain medication also 
contains Tylenol (acetaminophen)

-Make sure you drink plenty of fluids to help keep yourself 
hydrated and facilitate passage of stone fragments.

-You may shower and bathe normally. 
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation 
and constipation related to narcotic pain medication, 
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, unless otherwise noted.
-If you have fevers > 101.5 F, vomiting, severe abdominal pain, 
or inability to urinate, call your doctor or go to the nearest 
emergency room.

 
Followup Instructions:
___

{'lower back pain': ['Calculus of kidney', 'Lumbago'], 'pain': ['Calculus of kidney', 'Other acute postoperative pain'], 'urgency and frequency': ['Calculus of kidney', 'Stricture or kinking of ureter']}