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Medical Document Translation
University Clinical Center of the Republic of Srpska - Banja Luka, Bosnia and Herzegovina
Clinic for Hematology - Department of Conservative Hematology and Hemostasis Disorders
DOCUMENT 1 - ADMISSION HISTORY (Form "K" for Hematology)
Patient: LJUBAN (NIKOLA) JEFTIĆ
Residence: Prijedor
ID Number (JMBG): 2502956160017
Protocol No.: 239/26 | Date: 26.06.2026
ANAMNESIS (Medical History)
Patient History:
A 70-year-old patient who was referred to the Hematology Department of the General Hospital (OB) Prijedor for investigation of a suspected malignant etiology. During investigation the following were found:
- Hypercalcemia (high blood calcium)
- Progressive renal (kidney) impairment
- Multiple osteolytic bone lesions confirmed by skeletal scintigraphy
On the basis of the above findings, it was decided to hospitalize the patient at the University Clinical Center for specialist hematology evaluation and bone marrow biopsy.
Key Lab Values found:
- Calcium: 3.1 mmol/L (corrected with parenteral bisphosphonates down to 2.03 mmol/L)
- Elevated ESR (erythrocyte sedimentation rate)
- Hypoproteinemia
- Elevated serum IgG: 76.65 g/L
- BetaMG (Beta-2 Microglobulin): 20.3
- Progressive normocytic anemia with reduced reticulocytes
Bone Marrow Result (Myelogram): Confirmed hypercellular bone marrow with 90% infiltration by malignant plasma cells - confirming Multiple Myeloma (MM).
CT of Spine: Confirmed a compressive fracture of the L1 vertebra, with osteolytic changes in L3 and L5 of secondary (myelomatous) nature.
Hematology Board Decision: Treatment to begin according to the VCD protocol (Bortezomib, Cyclophosphamide, Dexamethasone). Prior to starting, the patient was referred to the Oncology Clinic for local radiotherapy (H-Ton) to the L1 and L5 vertebrae per the VCD protocol.
FAMILY HISTORY
No significant hereditary conditions noted.
ADDITIONAL DIAGNOSTIC PROCEDURES
Radiotherapy (H-Ton) of L1-L5 - 4 cycles completed.
GENERAL STATUS
Recent Symptoms & Current Presentation:
During the recent hospitalization, the patient's disease activity parameters were monitored. He takes medication regularly, without complaints. No fever, mild weakness, malaise, occasional pain in the bones. Appetite preserved. Stool: regular, normal color, no pathological material. Urine: normal, no dysuria. No hemorrhagic syndrome.
Zometa (bisphosphonate) infusion given: 10.06.2026 - administered via rapid IV NaCl infusion.
Recent Lab Values (early June 2026):
| Test | Value |
|---|---|
| IgA | 0.50 g/L |
| IgG | 15.13 g/L |
| IgM | 0.25 g/L |
| Free Kappa light chains | 29.8 mg/L |
| Free Lambda light chains | 25.3 mg/L |
| Beta-2 Microglobulin (B2MG) | 9.40 mg/L |
CURRENT STATUS (STATUS PRAESENS)
Physical Exam:
- Conscious, oriented, afebrile (no fever), breathing normally at rest
- No signs of hemorrhagic syndrome
- Heart: rhythmic action, tones clear, no murmurs. Blood pressure: 120/80 mmHg
- Lungs: normal vesicular breathing, no abnormal breath sounds
- Abdomen: flat, soft, non-tender on superficial and deep palpation. Normal ventral hernia present; no organomegaly (liver/spleen not enlarged)
- Extremities: no edema
EKG: Sinus rhythm, heart rate 75/min, left axis deviation (levogram), deep S in leads D3 and V3, ST-T without denivelation.
Blood Test Results (24.06.2026):
| Parameter | Value |
|---|---|
| Leukocytes (Le) | 6.4 x10⁹/L |
| ANC (Neutrophils) | 3.53 x10⁹/L |
| Lymphocytes (Lym) | 1.30 x10⁹/L |
| Monocytes (Mono) | 1.07 x10⁹/L |
| Erythrocytes (Er) | 3.64 x10¹²/L |
| Hemoglobin (Hgb) | 116 g/L |
| Hematocrit (Hct) | 0.356 L/L |
| MCV | 97.8 fL |
| Platelets (Tr) | 268 x10⁹/L |
| CRP | 22.8 mg/L |
CURRENT MEDICATIONS (Home Therapy)
| Medication | Dose | Frequency |
|---|---|---|
| Betaserc (betahistine - vertigo) | 24 mg | 1x daily |
| Forxiga (dapagliflozin - diabetes) | 10 mg | 1x daily |
| Altexurin (allopurinol - uric acid) | 100 mg | ½ tablet daily |
| Siofor (metformin - diabetes) | 1000 mg | 2x daily |
| Enap (enalapril - blood pressure) | - | 1x daily |
| Enap H (enalapril + hydrochlorothiazide) | - | 1x daily |
| Byol (bisoprolol - heart/BP) | - | 1x daily |
| Aspirin | 100 mg | 1x daily |
| Vitamin B complex | - | daily |
| Magnesium (Mg direct) | - | daily |
DOCUMENT 2 - REPORT AND OPINION (Nalaz i Mišljenje)
Protocol No.: 6498531/26 | Date: 26.06.2026
DIAGNOSES
| ICD Code | Diagnosis |
|---|---|
| C900 | Multiple Myeloma IIIB, IgG lambda, ISS Stage III |
| S320 | Pathological fracture of the L1 lumbar vertebra |
| - | Infiltration of vertebrae L3, L5, and posterior part of T9 (thoracic vertebra IX) |
| E119 | Type 2 Diabetes Mellitus without complications (insulin-independent) |
| I10 | Essential (Primary) Hypertension |
CLINICAL SUMMARY
A 70-year-old patient who was initially hospitalized at OB Prijedor Hematology Department for investigation of suspected malignant pathology. The following were found during workup:
- Hypercalcemia with progressive kidney impairment
- Multiple osteolytic lesions on skeletal scintigraphy
- Corrected calcium: 3.1 mmol/L (reduced to 2.03 with bisphosphonates)
- Elevated ESR, hypoproteinemia, IgG: 76.65 g/L, BetaMG 20.3
- Progressive normocytic anemia with reduced reticulocytes
Myelogram (bone marrow biopsy): Confirmed hypercellular marrow with 90% infiltration by malignant plasma cells - confirming Multiple Myeloma (MM).
CT Spine: Compressive fracture at L1, osteolytic changes at L3 and L5.
Hematology Board decision: Treatment using VCD protocol. Prior to VCD, patient referred to Oncology Clinic for local radiotherapy of L1 and L5. Patient subsequently received 5 cycles of local radiotherapy (H-Ton) to L1-L5.
Zometa (Zoledronic acid/bisphosphonate) infusion: given on 10.06.2026 via rapid IV NaCl infusion.
Current Symptoms: No major complaints, no fever, mild weakness and malaise, occasional bone pain. Appetite preserved. Normal stools and urination. No hemorrhagic signs.
PHYSICAL EXAMINATION
- Conscious, oriented, afebrile, eupneic
- Heart: rhythmic, tones clear, no murmurs. BP 120/80 mmHg
- Lungs: vesicular breathing, no adventitious sounds
- Abdomen: flat, soft, non-tender. Ventral hernia noted (at surface level); no organomegaly
- Extremities: no edema
EKG: Sinus rhythm 75/min, levogram (left axis), deep S in D3 and V3, ST-T without denivelation.
Blood Test (24.06.2026):
| Parameter | Value |
|---|---|
| Leukocytes | 6.4 x10⁹/L |
| ANC | 3.53 x10⁹/L |
| Lymphocytes | 1.30 x10⁹/L |
| Monocytes | 1.07 x10⁹/L |
| Erythrocytes | 3.64 x10¹²/L |
| Hemoglobin | 116 g/L |
| Hematocrit | 0.356 L/L |
| MCV | 97.8 fL |
| Platelets | 268 x10⁹/L |
| CRP | 22.8 mg/L |
PHYSICIAN'S OPINION & PLAN
The patient is confirmed to have Multiple Myeloma IgG lambda, ISS Stage III, with pathological vertebral fractures (L1, infiltration of L3, L5, T9). He completed local radiotherapy and received Zometa. He is currently being worked up to begin the VCD chemotherapy protocol.
Signed by: dr Snježana Opačić
Stamp: University Clinical Center of the Republic of Srpska - Clinic for Hematology, Banja Luka
Summary in Plain English
This is a hospital medical report for a 70-year-old man named Ljuban Jeftić from Prijedor (Bosnia and Herzegovina). He has been diagnosed with:
- Multiple Myeloma (a cancer of plasma cells in the bone marrow), Stage IIIB, ISS Stage III - a relatively advanced stage
- Pathological bone fractures of the spine (L1 vertebra collapsed due to the cancer, with additional cancer involvement at L3, L5, and T9)
- Type 2 Diabetes (managed with tablets)
- High blood pressure (managed with medications)
His bone marrow is 90% replaced by cancerous plasma cells. He has completed radiation therapy to his spine and received a bone-strengthening infusion (Zometa). He is now scheduled to start VCD chemotherapy (Bortezomib + Cyclophosphamide + Dexamethasone). His current blood counts show mild anemia (Hgb 116 g/L) but otherwise stable values.
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