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UNIVERSITY CLINICAL CENTRE OF THE REPUBLIC OF SRPSKA

Organizational Unit: 1015 CLINIC FOR HEMATOLOGY 10151 Department of Conservative Hematology and Hemostasis Disorders

FINDINGS AND OPINION

Patient name: LJUBAN (NIKOLA) JEFTIĆ / Prijedor / ID number: 2502956160017 Protocol number: 6498531/26 Date: 26.06.2026

Diagnoses:

C900 - Multiple Myeloma IIIB IgG lambda ISS III
S320 - Pathological fracture of lumbar vertebra, level L1
Infiltration of vertebrae L3, L5 and posterior part of vertebra IX
E119 - Diabetes mellitus, insulin-independent, without complications
I10 - Essential (primary) arterial hypertension

ANAMNESIS

This is a 70-year-old patient who was initially hospitalized at the Department of Hematology at the General Hospital in Prijedor for the workup of malignant hypercalcemia, progressive renal insufficiency, and multiple osteolytic lesions confirmed by scintigraphy. Initial laboratory analyses showed Ca 3.1, values corrected by parenteral bisphosphonate administration, ESR in the triple digits, hypoproteinemia, elevated serum IgG level of 76.65, beta-2 microglobulin 20.3, progressive normocytic anemia, and reduced reticulocyte count.

Based on the above, a suspicion of plasma cell dyscrasia (Multiple Myeloma) was raised. A myelogram confirmed hypercellular bone marrow with 90% infiltration by malignant plasma cells.

CT of the spine confirmed a compression fracture of the L1 vertebra, as well as osteolysis of L3 and L5 vertebrae of unclear etiology. The Hematology Council decided to begin treatment with chemotherapy according to the VCD protocol.

During the previous hospitalization at our Clinic, the 4th cycle of chemotherapy was administered.

The patient now presents for the 5th cycle of chemotherapy. Previously, on 10.06.2026, bisphosphonates were administered - Zometa in a rapid NaCl infusion.

In the period between the two hospitalizations, the patient had no complaints. No fever. Denies weakness, fatigue, chills, night sweats, and bone pain. Appetite preserved, regular bowel movements, formed stool, no blood in stool. Urinating regularly, no dysuria. Denies hemorrhagic syndrome.

Review of the most recent disease activity parameters from early June of this year:

TPR 69, Albumin 40, IgA 0.50, IgG 15.13, IgM 0.25, free kappa light chains 29.8, free lambda light chains 25.3, beta-2 microglobulin 9.40

FAMILY HISTORY: No hereditary diseases of significance.

DRUG ALLERGIES: None reported. Non-smoker. Does not consume alcohol.

Current therapy: Betaserc 24mg 1x1, Forxiga 10mg 1x1, Altexurem 100mg 1/2 tab, Siofor 1000mg 2x1, Enap 1x1, Enap H 1x1, Byol 1x1, Aspirin 100mg 1x1, Vitamin B complex, Mg direct.

CURRENT STATUS (STATUS PRAESENS)

Patient is clinically conscious, oriented, afebrile, breathing comfortably at rest. No signs of hemorrhagic syndrome. Heart rate is regular, heart sounds muffled, no murmurs heard, blood pressure 120/80 mmHg. Auscultation of lung fields reveals normal breath sounds. Abdomen is flat, soft, not tender on superficial or deep palpation, a formed ventral hernia is present, no organomegaly. Extremities without edema.

Enclosed (24.06.2026):

WBC 6.4, ANC 3.53, Lymphocytes 1.30, Monocytes 1.07
RBC 3.64, Hemoglobin 116, Hematocrit 0.356, MCV 97.8, Platelets 268
CRP 22.8

ECG: Sinus rhythm, rate 75/min, left axis deviation, deep S in lead D3, ST-T without deviation.

Physician: dr. Snježana Opačić (Stamp: Public Health Institution - University Clinical Centre of the Republic of Srpska - Clinic for Hematology - Banja Luka)

Printed: 26.06.2026 at 07:55:50

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