40/f has right flank pain since 15 days with burning micturition. no fever/hematuria no h/o left loin pain hypothyroidism (TSH: 11, on eltroxin 50ugOD) xray image given how to proceed in this case? hypothyroidism management??

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Left renal pelvis staghorn calculus and 2 calculi in upper ureter . KFT USG and IVP . Priority of surgery is on the side where hydronephrosis is more , most likely on right side . Right sided PCNL or ureterorenoscopy depending upon the site of calculus as confirmed by IVP / USG

40 yrs female with Two calculi in right upper ureter and staghorn calculus in left kidney She has burning micturition which indicate she has active infection, it need to be treated with antibiotics based on culture sensitivity She has right ureteric calculus and right flank pain suggesting right obstructed urinary system, along with urinary infection Urinary infection in setting of urinary track obstruction is difficult to treat and it has potential of increasing in severity, therefore obstruction need to be treated urgently At least right side Double J stent insertion will help in getting rid of obstruction and will help in treating infection She had raised TSH, Which need to be corrected by increasing eltroxin dose, 75 ug OD, recheck TSH after 1 month Finally, left kidney large staghorn indicate chronic infection The cause of such stone need to be investigated Check for diabetes, check HbA1c Check vitamin B 12 , vitamin D level Check for immune status, do vital marker for HIV, Hepatitis B and Hepatitis C Check post void residue in the bladder after passing urine, some times post void residue can be cause of recurrent and chronic urinary infection Check for serum calcium and phosphorus level, bilateral stone one need to rule out hyperparathyroidism, which will manifest as hypercalcaemia

Thank you all Cr is normal Ct ivp shows left complex stone and right upper ureteric stone(8mm&9mm) with moderate hn. No hun on left side I planned for right flex ursl/pushback pcnl

Staghorn calculus left pelvis kidney. Two calculus in Rt ureter.

Rt ureteric calculi lt calculi huge silent do urine rt usg rt uretric calculi appendicitis uti tb nodes

Staghom calculus at Lt. Renal pelvic region & Rt. Ureter calculi at middle 1/3 region.- needs PCNL for rt renal calculi

Lt renal calculus and rt middle third ureter. Renal function tests, USG and Ivp should be done. The more functional kidney should be operated first

Hypothyroidism management is to adjust Thyroxine dose as per the TSH levels. Go for KFT, USG KUB and IVP along with necessary investigations for pre-anaesthetic work up. More advanced optional investigations include NCCT-KUB, CT Urography and DTPA Renal scan. Treatment should be Left PCNL and Right PCNL/URS according to the level of Right ureteric calculi. Which side to be operated first will depend on the differential renal function. The side which is more functioning should be operated first followed by other side. Alternative best option is to go for Left PCNL and Right DJ Stent placement in one sitting followed by Right PCNL/URS on follow up.

Get PTH levels done also..
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Thank you all for your valuable suggestions!!!!

Left renal pelvis staghorn calculus

For hypothyroidism do antibodies titres. If anti TPO is high increase dose to 50micrograms and fup clinically to adjust. If antibody titre is normal follow up after treating stone pathology with thyroid function tests and then adjust the dose.
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