Oncologist epicrisis — start of imatinib
LLC "Medical clinic "Innovation"
Phone: (044) 331-21-00,
(067) 503-59-22
License AE 459319 dated August 27, 2014 issued by the Ministry of Health of Ukraine
www.innovacia.com.ua
Code for the Unified State Register of Enterprises and Organizations of Ukraine 36076865
MEDICAL DOCUMENTATION
Form of primary accounting
documentation No. 028/0
APPROVED
Order of the Ministry of Health
of Ukraine of February 14, 2012
No. 110
Epicrisis
Patient: Anastasia Stanislavivna Zherlitsyna, 47 y.o. Phone number: 0685975246 Patient's ID: 7140773 |
Insurance Company Policy No. Coordinator |
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Document No. IX-230502/5819.E1/1 Stationary card No.IX-230228/5668 dated 02.03.2023 Department: Polyclinic department |
from 08.05.2023 8:59:00 Doctor: Oksana Mykolaivna Latsinnikova |
The patient A.S.Zherlitsina, born in 1976, was treated from May 3 to 8, 2023 in the inpatient conditions of the "Innovation" clinic.
Diagnosis: GIST of the stomach with secondary liver damage.
Condition after EUS-FNA of gastric biopsy (April 21, 2023), liver core biopsy (April 25, 2023), histologically - gastrointestinal stromal tumor (GIST) of the stomach, GIST metastasis in the liver (CSD).
Condition after trepan biopsy of the liver (28.08.2022 NCI). Histopathological conclusion:uterine leiomyosarcoma.
Condition after 4 cycles of chemotherapy according to the Gemcitabine+Docetaxel+Avastin protocol with progression in the liver (MRI of the abdominal cavity, pelvic organs on 10/14/2022, CT scan on 12/01/2022).
Kit, MET mutations were detected (whole genome sequencing ONCOMINE, 12.2022).
Treatment with Pazopanib from January 5 to 12, 2023, with the development of the posterior reversible encephalopathy syndrome and positive dynamics according to CT data from February 9, 2023. Repeat liver biopsy (January 23, 2023, Oberig). Histopathological conclusion: metastasis of uterine leiomyosarcoma.
The condition after 3 cycles of chemotherapy according to the Trabectedin protocol with minimal negative dynamics according to the PET-CT data (11.04.2023): Known masses in the liver and the mass on the left, which according to the configuration rather originates from the stomach wall have slightly increased, are metabolically active. Masses in the uterus and in/near the right ovary with low metabolic activity, structurally stable. A significant difference in the activity of liver/stomach and uterine masses suggests different neoplastic processes, in particular, primarily aggressive from the stomach/GIST. The primary biopsy from 08.2022 is being reviewed in the CSD laboratory.
Associated diagnosis: Iron deficiency anemia. Type 2 diabetes mellitus, hypovitaminosis D.
Closed segmental fracture of the distal metaphysis of the left radius with displacement of fragments (11.02.2023p.)
Current hospitalization: start of treatment with Imatinib, symptomatic treatment (prophylaxis of tumor lysis syndrome).
13.02.2023 - Port-A-Cath Implantable System for Intravenous Infusions.
The patient has no active complaints at the time of examination.
Objectively: the general condition is satisfactory. The skin and visible mucous membranes are of normal color, clean, dry. Breathing is vesicular, can be heard throughout, there are no wheezes. The activity of the heart is rhythmic, the tones are muffled. The abdomen is soft, painless on palpation, the liver is enlarged to the level of the navel, peristalsis is active. Diuresis - sufficient, stool - 1 time / day, liquid.
Therapy carried out: Dexamethasone, Controloc, saline solutions, Eliquis, Glucophage, Sorbifer, Hepavista detox, Adenuric, soda, Calcium + D3.
The treatment was tolerated satisfactorily.
The results of the analyses were attached.
Recommended:
1. For nausea - Zofetron 8 mg (1 tab) orally 1 - 3 times a day, the maximum daily dose - 32 mg (4 tablets per day), it is also possible to take Cerukal 10-20 mg (1-2 tablets), up to 6 tablets per day, in 2-3 receptions.
2. In the case of mucositis (redness, swelling, ulceration of the mucous membrane of the oral cavity) - start treatment of the oral cavity with oral antiseptics (Oracept, Givalex, Stomatidin), if the condition worsens - Diflucan 150 mg orally (according to agreement).
3. Adherence to the drinking regime - consumption of at least 2 - 2.5 liters of liquid per day (ReO water) (under the control of diuresis and blood pressure indicators!)
4. If the skin is dry - use fatty creams and cosmetic oils, if the conjunctiva is dry - drops "Artificial Tears" or "Hylo-Care". For dryness of the nasal mucosa - spray "Aqua-Maris" or "Humer", "Marimer", oil solutions of Chlorophyllipt, sea buckthorn oil, olive oil. Treat the mucous membrane of the nose with Synthomycin ointment 2-3 times a day for 10 days.
5. General blood test once a week.
6. If the body temperature rises above 38°C, start antibacterial therapy (in consultation with the doctor!!!)
7. For constipation - Duphalac 20 ml 1 time a day every day after breakfast.
8. For diarrhea, start Imodium - 2 caps. immediately, then 1 capsule after each episode of loose stools (up to 8 capsules per day).
9. In case of deterioration of well-being - phone number of the doctor on duty 0968151618
10. Adenuric 80 mg daily.
11. Control of the level of vit D3 in 1 week.
12. Vitamin D3 at 4,000 unit/day for 3 months in total, control of the level of vit D3 in 2 weeks.
13. Follow the traumatologist's recommendations.
14. Follow the recommendations of the endocrinologist.
15. Hepavista - detox 1 tab 2 times a day.
16. Continue taking Imatinib 400 mg daily.
17. Control examination on May 15, 2023.
Clinical diagnosis
Main: Diagnosis: GIST of the stomach with secondary liver damage.
Doctor ______________________ / Latsinnikova O.M.