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CLINICAL COUNTY EMERGENCY HOSPITAL MURES CLINICAL HEMATOLOGY AND MARROW TRANSPLANT DEPARTMENT Targu-Mures – 35 Revolutiei DISCHARGE BILLET – MEDICAL LETTER TO THE FAMILY PHYSICIAN FO:95-2008 Seal applied
PERSONAL DATA: MOLDOVAN EMIL – 29 years old residing
HOSPITALIZATION PERIOD: 28.01.2008 – 14.02.2008 DIAGNOSIS: Mielodisplasic syndrome (AREB) D462 Febrile
SUBJECTIVE AFFECTIONS: asthenia, adinamy OBJECTIVE EXAMINATION: teguments and pale mucous, without palpable peripheral adenopathy, conformed normal thorax, present MV, symmetric, without rales, rhythmic cardiac noises, systolic blow gr 3/6 mesocardiac, liver, spleen in normal limits. PARACLINICAL INVESTIGATIONS: L: 3840, Hgb; 5.6/dl, Hct:16.7%, Plt: 84000, VSH 128/150, Fibrogen 474, Glycemia: 5.06, Creatinine: 0.93, Urea: 4.64, SGOT: 12, SGPT: 9, BiT 0.53, BiD 0.09, Cholesterol 3.44, Triglycerides 1.36, LDH: 337, Sideremy: 34.41, Uric acid: 226, Prot. Tot: 6.73, Na 150.0, K 4.62, Mg 0.83, Ca 2.31, IP: 80%. Urine summary examination: normal. Antigen negative HBs, Atc anti HBs total negative, Atc anti HBc-IgM negative, Atc anti HCV – negative, Atc anti CMV – IgM negative, Atc anti CMV IgG – positive. Pharyngeal exudates: absent pathogen bacterial flora. Negative mycological. Mycological from the tongue: negative. Uroculture: without bacterial increase, urine with antibacterial effect, ECG: RS, AV 79/min, intermediary ax QRS, where T negative in DII, aVR, aVF. CASE INTERPRETATION: ill without special pathological antecedents in hematological record with myelodysplasia syndrome from December 2007, for which he beneficiated from transfuses of erytrocitary mass presently hospitalized in our clinic for hematological reevaluation. We administer treatment with Cytostar. After the treatment a febrile granulocytopenia is installed and then we administered treatment with granulocyty increase factors (Neupogen), antibiotic treatment with large specter. Anemia was corrected with transfusions of eritrocitary mass disleukocyted and irradiated, thrombocitepenia with filtered and irradiated thrombocyte mass. Favorable evolution. ADMINISTERED TREATMENT: Cytosar 2x20 mg- 5 days, Osetron, Neupogen, total blood, erythrocyte concentrate, thrombocyte concentrate, Tienam, Axetin, Augmentin, Ciprofloxacin, Aciclovir, Medrol, Omeprazol, Dicarbocalm, Folic Acid. BLOOD TEST AT DISCHARGE: L 4210, Hgb 96 g/dl, Hct: 27.5%, Plt: 63000 RECOMMENDATIONS: Avoiding physical efforts. Treatment of intercurrent infections with antibiotics of large specter. In case of superinfection or persistence of febrile status, to be hospitalized at the Territory Hospital. Treatment continuation at domicile with: Amoxicilina 3x500 mg/day, Biseptol 2x1/day 3 days per week, Aciclovir 4x400 mg/day, Medrol 16 mg…lozenge/day, Famotidin 2x1/day.
RE-HOSPITALIZED ON: CONTROL IN 2 WEEKS TIME Clinics
I, the undersigned, Bucko Patricia, authorized translator by the Ministry of Justice, license no. 4218,
hereby certify that this is a true translation of the deed in Romanian language.
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