Oncologist epicrisis after the third Trabectedin administration
Ministry of health of Ukraine
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: Zherlitsyna Anastasia Stanislavivna, 46 y.o. Phone number: 0685975246 Patient's ID: 7140773 |
Insurance Company Policy No. Coordinator |
|---|---|
Document No. IX-230323/5716.E1/1 Stationary card No.IX-230208/5611 dated 15.02.2023 Department: Polyclinic department |
from 24.03.2023 10:57:00 Doctor: Oksana Mykolaivna Latsinnikova |
The patient Zherlitsina A.S., born in 1976, was treated from February 23 to 24, 2023 in the inpatient conditions of the "Innovation" clinic.
Diagnosis: Leiomyosarcoma of the uterus T2NxM1 (liver, peritoneum). State after trepan-biopsy of the liver on August 28, 2022. Pathohistological conclusion: leiomyosarcoma of the uterus.
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 October 14, 2022, CT scan on December 1, 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. Conclusion: CT signs of secondary damage to the liver parenchyma, interloop implant of the left mesogastric, volume formation in the projection of the right ovary (implant in the Douglas space?), minimal signs of biliary hypertension. From January 4, 2023, the dynamics are positive - regression of foci in the liver by 12%, decrease in the size of the interloop implant by 15%.
Repeat liver biopsy (January 23, 2023). Pathohistological conclusion: metastasis of uterine leiomyosarcoma.
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: 3rd cycle of chemotherapy according to the Trabectedin protocol (dose reduction by 20%).
13.02.2023 - Port-A-Cath Implantable System for Intravenous Infusions.
Complaints of languor, loose stools once a day.
Objectively: the general condition is satisfactory. The skin and visible mucous membranes are of normal color, clean. Breathing is vesicular, can be heard throughout, there are no wheezes. The activity of the heart is rhythmic, the tones are sonorous. The abdomen is soft, painless on palpation, the liver is enlarged to the level of the navel, peristalsis is active. Diuresis is sufficient, bowel movements - once a day, loose.
As part of the 3rd cycle of chemotherapy, the patient has received Yondelis 2 mg.
Concomitant therapy included Dexamethasone, Emend, Zofran, Controloc, Eliquis saline solutions, Glucophage, Sorbifer, Tivortin, Heptral, Glutargin, Saline solutions, Calcium + D3.
The treatment was tolerated satisfactorily.
The results of the analyses were attached.
In 2 weeks, a CT scan of the thoracic cavity, abdominal cavity and pelvis is scheduled.
Recommended:
1. Zofetron 8 mg (1 tab) orally 3 times a day for 3 days, then as needed, 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, water ReO (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. Sorbifer 1 tab once a day for 30 minutes before meals daily.
11. Eliquis 2.5 mg 2 times a day continued.
12. Vitamin D3 at 4,000 unit/day for 3 months in total.
13. Follow the traumatologist's recommendations.
14. Follow the recommendations of the endocrinologist.
15. Heptral 500 mg 2 times a day (morning, afternoon)
16. Calcium D3 1 tab 2 times a day during meals.
17. Emend 80 mg in the morning of February 26, 2023.
18. Zarzio 30 million subcutaneously from March 27 to 28, 2023, 30 minutes before the injection, take paracetamol 500 mg. Store in the refrigerator before use.
19. Ursofalk 500mg every evening.
20. Panangin 1 tab 3 times a day for 3 weeks.
21. Consultation of a neurologist (Y. O. Matiash, Dobrobut clinic).
Clinical diagnosis
Main: Diagnosis: Leiomyosarcoma of the uterus T2NxM1 (liver, peritoneum).
Doctor ______________________ / Latsinnikova O.M./