Discharge summary (hospitalisation 13–25 January 2023, PRES)
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
She was under inpatient treatment from January 13, 2023, 6:29 p.m. to January 25, 2023.
COMPLAINTS: weakness, drowsiness, headache.
CLINICAL DIAGNOSIS: Malignant neoplasm of the uterus, unspecified localization cT2NxM1 (liver, peritoneum) clinical group IV ECOG 2 (morphological verification is questionable due to lack of immunohistochemical examination and detection of specific EGFR receptors in the tumor). Condition after palliative chemotherapy.
Posterior reversible encephalopathy syndrome as a side effect of treatment with Votrient.
Diabetes mellitus, possibly induced by glucocorticoids, was first detected in a state of subcompensation (currently on the background of glucocorticoid use).
Anemia of chronic diseases
DISEASE HISTORY: At the time of hospitalization, the patient's cancer diagnosis was not verified. Since the summer of 2022, the patient has been treated for uterine leiomyosarcoma T2NxM1 (liver, peritoneum, brain?) at the "Innovation" clinic. On August 29, 2022, a biopsy of a metastatic node in the liver was performed: conclusion - more data for leiomyosarcoma metastasis; IGH was not performed. 4 courses of palliative chemotherapy (gemcitabine+docetaxel+avastin) were conducted.
After a course of chemotherapy at the beginning of January 2023, treatment with the drug Votrient was started. After a short period of time after starting to take the drug Votrient, the patient began to suffer from a headache, which worsened in a horizontal position, worsened every day and eventually became permanent. To reduce the headache, the patient took various pain relievers and blood pressure medications, which provided temporary relief. The patient remembers what she did on January 12, 2023, but remembers very poorly the events of January 13, 2023. According to her mother, on January 13, 2023, around 4:00 p.m., she was found unconscious at home with traces of foam around the mouth and was taken to the Oberig clinic by the emergency medical team.
LIFE ANAMNESIS: Tuberculosis. Denies venereal diseases. According to the patient, she had hepatitis many years ago. Allergic anamnesis is not burdensome. There is no history of arterial hypertension.
INSURANCE HISTORY: according to the patient, during the last 12 months, she has not been on a sick-leave.
RESULTS OF LABORATORY RESEARCH: 13.01.2023…Blood electrolytes (EasyStat)
Blood electrolytes (K+, Na+, Cl-): Na+ - 139,5 mmol/L, K+ - 3,77 mmol/L, Cl- - 100,9 mmol/L;
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
13.01.2023…CLINICAL BLOOD ANALYSIS
Complete blood count (ESR, analyzer parameters, leukocyte formula): White blood cells (WBC) - 9.83 ×10*9/l, Red blood cell (RBC) - 4.68 ×10*12/l, Hemoglobin (HGB) - 121 g/l, Hematocrit (HCT) - 39.5%, Platelet Count (PLT) - 150 ×10*9/l, Mean corpuscular volume (MCV) - 86.2 fL, Mean corpuscular hemoglobin (MCH) - 26.4 pg, Mean corpuscular hemoglobin concentration (MCHC) - 306 g/l, DIFFERENTIATION OF LEUKOCYTE POPULATION (ANALYZER) - , Relative number of neutrophils NEUT % - 92.7%, Relative number of lymphocytes LYM % - 4.8%, Relative number of monocytes MONO% - 1.9%, Relative number of eosinophils EO % - 0.1%, Relative number of basophils BASO % - 0.5%, Absolute count of neutrophils NEUT # - 9.11 G/l, Absolute count of lymphocytes LYM # - 0.47 G/l, Absolute count of monocytes MONO # - 0.19 G/l, Absolute count of eosinophils EO # - 0.01 G/l, Absolute number of basophils BASO # - 0.05 G/l, Red blood cell distribution width-standard deviation (RDW-SD) - 68.2 fL, Red cell distribution width–coefficient of variation (RDW-CV) - 24%, Platelet distribution width (PDW) - 10.4 fL, Mean platelet volume (MPV) - 9,5 fL, Platelet-large cell ratio (P-LCR) - 22.8%, Plateletcrit (PCT) - 0.14%, Erythrocyte Sedimentation Rate (ESR) by Westergren method - 63 mm/h, LEUKOCYTE FORMULA (MANUAL) - , Band Neutrophils (%) - 15%, Segmented Neutrophils (%) - 76%, Monocytes (%) - 2%, Lymphocytes (%) - 7%, Eosinophils (%) - 0%;
13.01.2023…Biochemical research
Alanine transaminase (ALT) - 32.00 U/L; Aspartate Transferase (AST) - 49.60 U/L; Gamma-glutamyl transferase (GGT) - 96.90 U/L; Alkaline phosphatase (ALP) - 296.00 U/L; Lactate dehydrogenase (LDH) - 630.60 U/L; Bilirubin total - 12.30 umol/L; Bilirubin direct - 5.20 umol/L; Urea - 3.12 mmol/L; Cholinesterase (CHE) - 6 290 U/L; Creatinine - 87.14 umol/L, Estimated Glomerular Filtration Rate (eGFR) - 68.7 ml/min; Uric acid - 307,10 umol/L; Albumin - 40,67 g/L; Note - ;
13.01.2023…Determination of blood group and Rh factor (gel filtration)
Determination of blood group and Rh factor (gel filtration method): Blood group - 0 (I), Rhesus factor (RhD) (-) negative, Control materials - DiaClon ABO/D+reverse grouping for patients ( LOT 50092. 16.04) are valid until 23.01.2023); Standard erythrocytes Kyiv City Blood Center A (II) Rh+series No.08 are valid until 23.01.2023; B (llI) Rh+series No.08 are valid until 23.01.2023.;
14.01.2023…Study of the hemostasis system
Coagulogram (INR, TT, APTT, BT): Examination of the hemostasis system (Sysmex 600) -, Prothrombin time (PT) 12.3 sec, Prothrombin index - 91%, International normalized ratio (INR) - 1.10, Thrombin time (TT) - 19.6 sec, Activated partial thromboplastin time (aPTT) - 27.4 sec, Fibrinogen (Fg) - 3.42 g/L;
14.01.2023...Biochemical research
C-reactive protein (quantitative) (CRP) - 44.14 mg/L; Note - ;
17.01.2023...Blood electrolytes (EasyStat)
Blood electrolytes (K+, Na+, Cl-): Na+ - 135,6 mmol/L, K+ - 3,7 mmol/L, Cl- - 104,1 mmol/L;
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
17.01.2023…CLINICAL BLOOD ANALYSIS
Complete blood count (analyzer parameters, leukocyte formula): White blood cells (WBC) - 11.02 ×10*9/l, Red blood cell (RBC) - 4.04 ×10*12/l, Hemoglobin (HGB) - 107 g/l, Hematocrit (HCT) - 35.5%, Platelet Count (PLT) - 198 ×10*9/l, Mean corpuscular volume (MCV) - 87.9 fL, Mean corpuscular hemoglobin (MCH) - 26.5 pg, Mean corpuscular hemoglobin concentration (MCHC) - 301 g/l, DIFFERENTIATION OF LEUKOCYTE POPULATION (ANALYZER) - , Relative number of neutrophils NEUT % - 76.9%, Relative number of lymphocytes LYM % - 15.1%, Relative number of monocytes MONO% - 7.5%, Relative number of eosinophils EO % - 0%, Relative number of basophils BASO % - 0.5%, Absolute count of neutrophils NEUT # - 8.47 G/l, Absolute count of lymphocytes LYM # - 1.66 G/l, Absolute count of monocytes MONO # - 0.83 G/l, Absolute count of eosinophils EO # - 0 G/l, Absolute number of basophils BASO # - 0.06 G/l, Red blood cell distribution width-standard deviation (RDW-SD) - 73.9 fL, Red cell distribution width–coefficient of variation (RDW-CV) - 23.9%, Platelet distribution width (PDW) - 12.2 fL, Mean platelet volume (MPV) - 10,1 fL, Platelet-large cell ratio (P-LCR) - 28.3%, Plateletcrit (PCT) - 0.2%, LEUKOCYTE FORMULA (MANUAL) - , Band Neutrophils (%) - 5%, Segmented Neutrophils (%) - 72%, Monocytes (%) - 7%, Lymphocytes (%) - 16%, Eosinophils (%) - 0%;
17.01.2023…Biochemical research
C-reactive protein (quantitative) (CRP) - 12.74 mg/L;
19.01.2023…CLINICAL BLOOD ANALYSIS
Complete blood count (ESR, analyzer parameters, leukocyte formula): White blood cells (WBC) - 12.84 ×10*9/l, Red blood cell (RBC) - 3.85 ×10*12/l, Hemoglobin (HGB) - 102 g/l, Hematocrit (HCT) - 34.2%, Platelet Count (PLT) - 239 ×10*9/l, Mean corpuscular volume (MCV) - 88.8 fL, Mean corpuscular hemoglobin (MCH) - 26.5 pg, Mean corpuscular hemoglobin concentration (MCHC) - 298 g/l, DIFFERENTIATION OF LEUKOCYTE POPULATION (ANALYZER) - , Relative number of neutrophils NEUT % - 73.3%, Relative number of lymphocytes LYM % - 16.5%, Relative number of monocytes MONO% - 9.8%, Relative number of eosinophils EO % - 0%, Relative number of basophils BASO % - 0.4%, Absolute count of neutrophils NEUT # - 9.41 G/l, Absolute count of lymphocytes LYM # - 2.12 G/l, Absolute count of monocytes MONO # - 1.26 G/l, Absolute count of eosinophils EO # - 0 G/l, Absolute number of basophils BASO # - 0.05 G/l, Red blood cell distribution width-standard deviation (RDW-SD) - 77.3 fL, Red cell distribution width–coefficient of variation (RDW-CV) - 24.7%, Platelet distribution width (PDW) - 11.4 fL, Mean platelet volume (MPV) - 9,8 fL, Platelet-large cell ratio (P-LCR) - 25.2%, Plateletcrit (PCT) - 0.23%, Erythrocyte Sedimentation Rate (ESR) by Westergren method - 30 mm/h, LEUKOCYTE FORMULA (MANUAL) - , Band Neutrophils (%) - 5%, Segmented Neutrophils (%) - 68%, Monocytes (%) - 8%, Lymphocytes (%) - 20%;
19.01.2023...Blood electrolytes
Blood electrolytes (K+, Na+, Cl-): Na+ - 138,1 mmol/L, K+ - 5 mmol/L, Cl- - 106,7 mmol/L;
19.01.2023....D-Dimer (quantitative) - a biomarker of PE and deep vein thrombosis
D-Dimer (citrate plasma) - 0.11 mg/L;
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
19.01.2023...Procalcitonin - a biomarker for severe bacterial infections and sepsis
Procalcitonin - < 0.1 ng/ml;
19.01.2023…Biochemical research
Alanine transaminase (ALT) - 58.50 U/L; Aspartate Transferase (AST) - 35.70 U/L; Gamma-glutamyl transferase (GGT) - 109.00 U/L; Alkaline phosphatase (ALP) - 133.80 U/L; Lactate dehydrogenase (LDH) - 313.30 U/L; Bilirubin total - 3.15 umol/L; Bilirubin direct - 1.50 umol/L; Cholinesterase (CHE) - 5 419 U/L;
Note - ;
19.01.2023...Determination of glycated hemoglobin HbA1c
Glycated hemoglobin (HbA1c): Glycated hemoglobin (NGSP) (the average level of glucose in the blood during the life of erythrocytes over the past 2 to 3 months) - 6.59%, Additional information: glycated hemoglobin is used for population screening, as well as for monitoring treatment patients with diabetes - According to the recommendations of WHO (2002), even minor violations of carbohydrate metabolism are a risk factor for vascular complications. The level of vascular risk depends on glycated hemoglobin., CONCLUSION - Prediabetes is possible (carbohydrate metabolism disorder), to consult an endocrinologist or therapist.;
19.01.2023…Biochemical research
Iron - 8.59 µmol/L; C-reactive protein (quantitative) (CRP) - 6.81 mg/L; Note - ;
19.01.2023…Biochemical research
Transferrin: Iron - 8.59 nmol/L, Transferrin - 3.37 g/l, Iron transferrin saturation (TS) - 9.96%;
23.01.2023…CLINICAL BLOOD ANALYSIS
Complete blood count (analyzer parameters, leukocyte formula): White blood cells (WBC) - 11.26 ×10*9/l, Red blood cell (RBC) - 3.7 ×10*12/l, Hemoglobin (HGB) - 100 g/l, Hematocrit (HCT) - 32.5%, Platelet Count (PLT) - 329 ×10*9/l, Mean corpuscular volume (MCV) - 87.8 fL, Mean corpuscular hemoglobin (MCH) - 27 pg, Mean corpuscular hemoglobin concentration (MCHC) - 308 g/l, DIFFERENTIATION OF LEUKOCYTE POPULATION (ANALYZER) - , Relative number of neutrophils NEUT % - 54,6%, Relative number of lymphocytes LYM % - 28.7%, Relative number of monocytes MONO% - 14.7%, Relative number of eosinophils EO % - 1,7%, Relative number of basophils BASO % - 0.3%, Absolute count of neutrophils NEUT # - 6.15 G/l, Absolute count of lymphocytes LYM # - 3.23 G/l, Absolute count of monocytes MONO # - 1.66 G/l, Absolute count of eosinophils EO # - 0.19 G/l, Absolute number of basophils BASO # - 0.03 G/l, Red blood cell distribution width-standard deviation (RDW-SD) - 76.6 fL, Red cell distribution width–coefficient of variation (RDW-CV) - 25.7%, Platelet distribution width (PDW) - 10.6 fL, Mean platelet volume (MPV) - 9,5 fL, Platelet-large cell ratio (P-LCR) - 21.9%, Plateletcrit (PCT) - 0.31%, LEUKOCYTE FORMULA (MANUAL) - , Band Neutrophils (%) - 2%, Segmented Neutrophils (%) - 59%, Monocytes (%) - 12%, Lymphocytes (%) - 24%; Eosinophils (%) - 3%, ERYTHROCYTE MORPHOLOGY -, DEGENERATIVE CHANGES IN LEUKOCYTES -;
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
23.01.2023…Biochemical research
Calcium total, Ionized calcium: Calcium - 2.09 mmol/L, Ionized calcium (Ca++) - 1.05 mmol/L, C-reactive protein (quantitative) (CRP) - 3.58 mg/L; Note - ;
23.01.2023…25-hydroxycholecalciferol (25(OH) Vitamin D)
25-hydroxycholecalciferol (25(OH) Vitamin D) - 20.9 ng/ml
23.01.2023…Markers of the functional state of the thyroid gland
Thyroid-stimulating hormone (TSH) - 3.9 µlU/mL;RESULTS OF INSTRUMENTAL RESEARCH: 13.01.2023. MRI of the brain (Kovratko M. M.)
ZHERLITSYNA A.S. MRI of the brain Research number: 3251 dated 13.01.2023. Name of the institution (its division) that referred the patient for research: self-referral. The study was performed on: 1.5T Magnetom Sempra MRI system manufactured by Siemens Healthcare. Contrast enhancement: was used. Clinical task: from the anamnesis - uterine cancer (leiomyosarcoma). Medical documentation is not presented.
Research protocol: Diffuse changes in the cortico-subcortical substance are detected on a series of brain MRI scans in the frontal, parietal, and occipital-temporal areas on both sides, which are characterized by hyperintense and T2/T2_dark_fluid-WI and hypointense and T1-WI MR signals, without signs of diffusion restriction on DWI/ADC and showing moderate diffuse-spot contrast enhancement. During the preliminary MR examination for September 20, 2022. - these changes were not determined. Middle structures without signs of lateral displacement. The ventricles of the brain are not expanded, the lateral ones are relatively symmetrical. Cerebellar tonsils are located normally. Convexity subarachnoid spaces, the cisterns of lateral cerebral fossae are not expanded. No changes in MR signal intensity were detected in the pituitary gland and chiasm, basal ganglia, craniovertebral junction and cerebellopontine angles. The eyeballs are symmetrical, the retrobulbar spaces and the optic nerves look normal. Pneumatization of the paranasal sinuses and mastoid processes has not changed. No foci of an aggressive nature were detected in the bones of the base and the cranial vault.
CONCLUSIONS: From the anamnesis - uterine cancer, condition after palliative chemotherapy. The detected MR image of diffuse-focal changes in the cortico-subcortical substance of both cerebral hemispheres, taking into account the severe clinical course, requires differentiation between the manifestations of the inflammatory / autoimmune process (including vasculitis), instead the secondary mts-genesis of the changes is much less likely. In addition, the radiological MR image may be similar to the manifestations of CNS lymphoma, but taking into account the lack of changes in DWI sequences, the probability of the process is questionable. MR data for the presence of foci of fresh MVP or intracerebral hemorrhage were not detected.
Recommended: consultation of a neuropathologist, oncologist, radiological-laboratory correlation, short MRI control after a course of corticosteroid therapy.
20.01.2023…MRI of the brain and intra-extracranial arteries with contrast
ZHERLITSYNA A.S. MRI of the brain and intra-extracranial arteries with contrast Research number: 7091 dated 20.01.2023. Name of the institution (its division) that referred the patient for research: the hospital. The study was
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
performed on: 3T VIDA MRI system manufactured by Siemens Healthcare. Contrast enhancement: Dotavist 14 ml, intravenously, 3 ml/sec. Clinical task: the data of the previous MRI from January 13, 2023 were taken into account.
PROTOCOL OF THE CONCLUSION OF MRI OF THE BRAIN
BRAIN PARENCHYMA: Diffuse changes in the cortico-subcortical substance are preserved in the frontal, parietal and occipitotemporal areas on both sides, with a moderate decrease in the dynamics of manifestations of cortical hyperintensity at the level of the frontal and temporal lobes, with residual moderate diffuse-spotted contrast enhancement. Currently, on the cortex of both sides of the parietal lobes in the parasagittal sections, there are spots of cytotoxic edema (3 units), the length of which is up to 8.20 mm. In addition, in the left occipital lobe, against the background of the previously detected changes, a focus of intracerebral hemorrhage, measuring up to 13×12×25 mm, surrounded by moderate cerebral vasogenic edema is determined. Mesencephalic structures, structures of the posterior cranial fossa, and the brainstem do not contain areas of pathological changes in the MR signal. Craniovertebral junction without features. No mass effect or displacement of midline structures. VENTRICLES AND CONVEXITY EXTRA-AXIAL SPACES: There is no hydrocephalus, the ventricles of the brain are not dilated, the lateral ones are relatively symmetrical. EXTRA-AXIAL STRUCTURES: Visualized structures are normal. MRA OF THE BRAIN: No aneurysm was found. MRA shows irregularity of the vessels of the anterior, middle, and posterior cerebral arteries with multifocal segments of vasospasm, giving a "string-of-beads" appearance. MRA OF THE NECK: GENERAL TRUNKS: Visualized segments are intact. RIGHT ICA: without stenosis by NASCET criteria at the caroid bifurcation. LEFT ICA: without stenosis by NASCET criteria at the caroid bifurcation. VERTEBRAL ARTERIES: Typical extracranial segments, D>S
CONCLUSION: MR image of diffuse-focal changes in the cortico-subcortical substance of both hemispheres of the brain, with a predominance of changes in both occipital lobes, with the appearance in dynamics of foci of cytotoxic edema of the cortex of both parietal lobes, intracerebral hemorrhage of the left occipital lobe, and signs of cerebral vasculopathy with multifocal stenotic segments of vasoconstriction. The described changes, taking into account the severe clinical course, are typical and characteristic of - Posterior Reversible Encephalopathy Syndrome (PRES), with intracerebral hemorrhage and cerebral vasculopathy.
20.01.2023…ULTRASONOGRAPHY OF THE ORGANS OF THE ABDOMINAL CAVITY AND RETROPERITONEAL SPACE (COMPLEX).
The LIVER is enlarged, the thickness of the right lobe is 140 mm, the thickness of the left lobe is 100 mm. The contours of the particles are even and clear. The echo structure is heterogeneous, fine-grained in free areas, echogenicity of the parenchyma is average. In the right lobe, a cystic-solid formation ~ 16×12×15 cm with cystic cavities up to 10 cm in length. A formation of a similar structure on the border of the right and left lobes ~5 cm in d. In the modes of coloring are avascular. Intrahepatic bile ducts are not detected by ultrasound. V. Portae not expanded. Hepatic veins, inferior vena cava, abdominal aorta are not changed.
GALLBLADDER and common bile duct are not detected in the available scan modes.
PANCREAS: Visualization is satisfactory. The dimensions correspond to the normative values: 24x15x21 mm. Contours are even, clear. The echogenicity of the parenchyma is average. The structure is homogeneous and fine-grained. Duct of Wirsung is not dilated. In the caudal direction from the tail, an avascular hypoechoic formation ~5 cm of irregular oval shape with clear even contours, homogeneous hypoechoic structure will be determined. SPLEEN not enlarged, 99x35mm. The contours are even and clear, the echogenicity is average, the structure is homogeneous. Free liquid in the abdominal cavity is determined in layers up to 2.5 cm thick. KIDNEYS of age-sized, typically located. Respiratory motility is preserved. The shape has not changed, the contours are even and clear. Parenchyma of medium echogenicity. No focal changes were detected.
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
Corticomedullary differentiation is preserved. Vascularizing is not changed. The thickness of the parenchyma corresponds to age-standard values. The collecting duct system is not expanded. RIGHT KIDNEY: 117x58mm. LEFT KIDNEY: 119x59mm.
CONCLUSION: ultrasound signs of focal liver changes, small hydroperitoneum, mts?abdominal cavity. Hepatomegaly.
CONSULTATIONS OF SPECIALISTS: 16.01.2023…ADVISORY OPINION OF THE HEAD OF THE STROKE CENTER, CANDIDATE OF MEDICAL SCIENCES, ASSOCIATE PROFESSOR, HONORED PHYSICIAN OF UKRAINE Y.V.
CONCLUSION: Given the close temporal relationship between neurological disorders and the start of Votrient treatment and the possibility of such side effects as headache, increased blood pressure, convulsions and posterior reversible encephalopathy syndrome listed in the instructions for this drug, the most likely cause of the patient's disorders is PRES as a side effect of Votrient treatment. Differential diagnosis should be carried out with other subacute leukoencephalopathies, in particular of an autoimmune and toxic nature, and the reversible cerebral vasoconstriction syndrome (RCVS).
RECOMMENDED: 1. Refuse treatment with Vontrient.
2. Consider the possibility of pulse therapy with methylprednisolone (500 mg IV once a day in the morning N3) with correction of possible hypertension, hypoglycemia or electrolyte disturbances.
3. Repeated MRI of the brain with MRA of extracranial and intracranial arteries one week after the first examination (January 20, 2023).
4. Chemotherapy consultation regarding further treatment.
5. Complete cessation of smoking.
20.01.2023…ADVISORY OPINION OF THE ENDOCRINOLOGIST, HONORED DOCTOR OF UKRAINE (L.F. Taran)
DIAGNOSIS (specialist's opinion): Diabetes mellitus, not excluded, induced by glucocorticoids, first detected in a state of subcompensation (currently on the background of glucocorticoid use).
RECOMMENDED: : EXAMINATION:
1. Thyrotropic hormone
2. 25-hydroxyvitamin D, 25-(OH)D
3. Calcium total, ionized calcium
4. Glycemic control at 7 am, 11 am, 3 pm, 8 pm
5. Control of the level of blood glucose and glycohemoglobin after 3 months
6. Re-examination after 3 months
TREATMENT:
7. Diabetic diet
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
8. Glucophage XR 1000 mg per 1/2 tablet in the evening after meals for 1 week, then 1 tab in the evening after meals for 1 week, then 1.5 tabs in the evening after meals for 1 week, then 2 tabs in the evening after meals continuously until the next visit to the endocrinologist
9. In case of high glycemic index - Forxiga (dapagliflozin) or Jardins (empagliflozin): 10 mg each in the morning, regardless of food intake, continuously until the next visit to the endocrinologist
10. Insulin Actrapid 4-8 units with hyperglycemia above 10 mmol/L
11. Dekristol D3 in tablets of 4000 IU, 1 tab once a day until April inclusive
23.01.2023…ADVISORY OPINION OF THE HEAD OF THE STROKE CENTER, CANDIDATE OF MEDICAL SCIENCES, ASSOCIATE PROFESSOR, HONORED PHYSICIAN OF UKRAINE Y.V. FLOMIN (Flomin Y.V.)
CONCLUSION: The most likely cause of the patient's disorders is posterior reversible encephalopathy syndrome (PRES) as a side effect of Votrient treatment.
RECOMMENDED:
1. Stop taking Vontrient.
2. Complete cessation of smoking.
3. Add to treatment Aspirin cardio 100 mg 1 time a day - for a long time, as well as Ketilept 25 mg 1 time a day at night - 1 week.
4. Increase motor activity (at least 3-4 thousand steps per day).
5. Observation by an oncologist, to consider the issue of long-term drug prevention of venous thrombosis and thromboembolism.
24.01.2023…ADVISORY OPINION OF THE ONCOGYNECOLOGIST (Yefimenko A.A.)
COMPLAINTS: : at the time of examination:
DISEASE HISTORY: : 28.08.2022, according to the biopsy data, the diagnosis was established: leiomyosarcoma of the uterus T2NxM1 (liver, peritoneum), (histological examination of a trephine biopsy of a metastatic liver lesion, the description is doubtful, IHC was not performed), she received polychemotherapy courses (gemcitabine + docetaxel + avastin), is currently using Pazopanib (Votrient) 800 mg/day since 05.01.23, on the 2-3rd day for the first time she noticed a headache and an increase in blood pressure to 150-160 mm Hg, Eliquis 2.5 mg/day, also unsystematically prescribed antihypertensives and NSAIDs because of headaches. On 13.01.2023, she was hospitalized in the inpatient unit of the Oberig clinic with a generalized seizure, an MRI of the brain was performed, she was consulted by the head of the stroke center, Candidate of Medical Sciences, Honored Doctor of Ukraine Flomin, a posterior reversible encephalopathy syndrome (PRES) was detected as a side effect of treatment with Votrient. Referred to a consultation with an oncologist.
RESULTS OF THE EXAMINATION::
LIFE ANAMNESIS:: Gynecologic anamnesis. Menstruation from the age of 11, for 5-7 days, after 28 days: moderate, without pain. The last menstruation and its nature: medical menopause.
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
Contraception: - Operations: appendectomy in childhood. Somatic history: brain injury, Botkin's disease in 2002. Family oncological history burdened - mother's uterine cancer at 68 years old
DATA OF OBJECTIVE EXAMINATION:: External genitals: no features. Crotch: unchanged. Vagina: narrow. Vaginal wall: unchanged. Cervix: unchanged, conical shape. External orifice: rounded. Discharge: mucous. P.V: The cervix is cylindrical, conical. In the pelvis, a three-dimensional mass with clear contours measuring 9x14 cm in size, motionless, painful, can be palpated. Parameters are not infiltrated.
DIAGNOSIS (specialist's opinion):: [C55] Malignant neoplasm of the uterus, unspecified localization cT2NxM1 (liver, peritoneum) clinical group IV ECOG 2 (morphological verification is questionable due to the lack of an immunohistochemical study and detection of specific EGFR receptors in the tumor)
RECOMMENDED:: A trephine biopsy of the metastatic focus of the liver was taken, should resolve the question of further management after obtaining a histological examination and IHC. Do not return to the appointment of targeted tyrosine kinase inhibitors (Pazopanib).TREATMENT CARRIED OUT: Pulse therapy Solu-Medrol 500 mg intravenously in a saline solution 200.0 for three days from 17.01.2023 to 19.01.2023, dexamethasone 12 mg intravenously dropwise with a gradual dose reduction, dynastat 40 mg intravenously, clexane 0.4 subcutaneous 1 time a day, tab amlodipine 5 mg in the evening, proxium 40 mg, tab glucophage 500 mg in the evening.
On January 24, 2023, a percutaneous trephine biopsy of the liver lesion was performed under ultrasound control, the material was sent for histological examination.
TREATMENT RESULTS: improvement.
RECOMMENDED: Follow-up by a family doctor.
Observation by an oncologist, to consider the issue of long-term drug prevention of venous thrombosis and thromboembolism.
A trephine biopsy of the metastatic focus of the liver was taken. To resolve the question of further management after obtaining a histological examination and IHC.
Do not return to the appointment of targeted tyrosine kinase inhibitors (Pazopanib).
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
DISCHARGE SUMMARY
Patient: Zherlitsyna Anastasia Stanislavivna, 46 years old
Stationary card No. 00054
Date: 25.01.2023
TREATMENT:
Diabetic diet. Increase motor activity (at least 3-4 thousand steps per day).
Glucophage XR 1000 mg per 1/2 tablet in the evening after meals for 1 week, then 1 tab in the evening after meals for 1 week, then 1.5 tabs in the evening after meals for 1 week, then 2 tabs in the evening after meals continuously until the next visit to the endocrinologist
In case of high glycemic index - Forxiga (dapagliflozin) or Jardins (empagliflozin): 10 mg each in the morning, regardless of food intake, continuously until the next visit to the endocrinologist
Aspirin cardio 100 mg 1 time a day - for a long time, as well as Ketilept 25 mg 1 time a day at night - 1 week
Dekristol D3 in tablets of 4000 IU, 1 tab once a day until April inclusive
Clexane 0.4 subcutaneous 1 time a day. (1 tablet per week until consulting a chemotherapist)
Calcium D3 – nycomed osteoforte 1 tab in the evening - 3 months.
Heptral tab 500 mg 1 tab twice a day between meals (8 am and 4 pm) for 1 month.
Tab proxium 40 mg 1 tab in the morning before breakfast for 3 weeks.
Treating doctor: Antonyuk L.I. _____________
Branch manager: Yurkiv Oleg Yevhenovich _________________
Recommendations regarding treatment and the need to follow it were given to me in an understandable form
_________________________ signature
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
Research results
Order date: 17.01.2023 Order No. 28939327 * - indicator of the zone of
Patient: Zherlitsyna Anastasia Stanislavivna increased attention
Date of birth: 25.04.1976 Contract: clinic Oberig Kyiv
Age: 46 years 8 month old Point: Autoimport Corp. Office
Sex: Female Doctor:
| Indicator | Result | Unit | Reference range |
|---|---|---|---|
| Immunology-ELISA | |||
Antinuclear antibodies (ANA, IFT method) Package No. 5.11 (ANCA IgG antibodies) |
*1:100 | Titer | < 1:100 - negative result |
| Lactoferrin, IgG_ANCA antibodies | < 0.1 | R | <1.0 - negative result ≥1.0 - <2.0 - weakly positive result ≥2.0 - <5.0 - positive result ≥5.0 - strongly positive result Method: Enzyme-linked immunosorbent assay (ELISA) Reagents: Euroimmun (Germany) Analyzer: EUROIMMUN Analyzer I (Germany) |
| Neutrophil elastase, IgG_ANCA antibodies | < 0.1 | R | <1.0 - negative result ≥1.0 - <2.0 - weakly positive result ≥2.0 - <5.0 - positive result ≥5.0 - strongly positive result Method: Enzyme-linked immunosorbent assay (ELISA) Reagents: Euroimmun (Germany) Analyzer: EUROIMMUN Analyzer I (Germany) |
| Cathepsin G, IgG_ANCA antibodies | < 0.1 | R | <1.0 - negative result ≥1.0 - <2.0 - weakly positive result ≥2.0 - <5.0 - positive result ≥5.0 - strongly positive result Method: Enzyme-linked immunosorbent assay (ELISA) Reagents: Euroimmun (Germany) Analyzer: EUROIMMUN Analyzer I (Germany) |
| Bactericidal/permeability-increasing protein (BPI), IgG_ANCA antibodies | 0.2 | R | <1.0 - negative result ≥1.0 - <2.0 - weakly positive result ≥2.0 - <5.0 - positive result ≥5.0 - strongly positive result Method: Enzyme-linked immunosorbent assay (ELISA) Reagents: Euroimmun (Germany) Analyzer: EUROIMMUN Analyzer I (Germany) |
The results of laboratory tests are not a sufficient basis for making a diagnosis.
Interpretation of results and making a diagnosis is performed only by a doctor.
Processing of material and issuance of results is carried out using the laboratory information system SILAB.
LLC CAPITAL
License of the Ministry
of Health of Ukraine
AG No. 599781
dated January 17, 2012
MEDICAL DOCUMENTATION
Institution code for the All-Ukrainian Classifier of Enterprises and Organizations: 32381903
Universal clinic "Oberig"
3 Zoolohichna Street, Kyiv, 03057, Ukraine
(044) 521-30-03
emergency aid 3003
5213003@oberig.ua
Research results
Order date: 17.01.2023 Order No. 28939327 * - indicator of the zone of
Patient: Zherlitsyna Anastasia Stanislavivna increased attention
Date of birth: 25.04.1976 Contract: clinic Oberig Kyiv
Age: 46 years 8 month old Point: Autoimport Corp. Office
Sex: Female Doctor:
| Myeloperoxidase (MPO), IgG_ANCA antibodies | 0.8 | R | <1.0 - negative result ≥1.0 - <2.0 - weakly positive result ≥2.0 - <5.0 - positive result ≥5.0 - strongly positive result Method: Enzyme-linked immunosorbent assay (ELISA) Reagents: Euroimmun (Germany) Analyzer: EUROIMMUN Analyzer I (Germany) |
|---|---|---|---|
| Proteinase 3 (PR3), IgG_ANCA antibodies | < 0.1 | R | <1.0 - negative result ≥1.0 - <2.0 - weakly positive result ≥2.0 - <5.0 - positive result ≥5.0 - strongly positive result Method: Enzyme-linked immunosorbent assay (ELISA) Reagents: Euroimmun (Germany) Analyzer: EUROIMMUN Analyzer I (Germany) |
Note:
____________________ Dmytrenko O.V.
The results of laboratory tests are not a sufficient basis for making a diagnosis.
Interpretation of results and making a diagnosis is performed only by a doctor.
Processing of material and issuance of results is carried out using the laboratory information system SILAB.