University Clinical Center of the Republic of Srpska

Clinic for Hematology - Banja Luka

Admission / Discharge Form "K" for Hematology

Patient: Ljuban (Nikola) Jeftić ID Number (JMBG): 2502956160017 (Date of Birth: February 25, 1956) Date: June 26, 2026 Attending Physician: Dr. Snježana Opačić

ADMISSION ANAMNESIS

Personal History (Anamnesis): A 70-year-old patient who was initially hospitalized at the Hematology Department of the General Hospital Prijedor for investigation of suspected malignant hypercalcemia (elevated calcium levels), progressive kidney impairment, and multiple osteolytic (bone-destroying) lesions confirmed by skeletal radiography.

Family History: Not specified.

Additional Diagnostic Procedures:

Bone marrow biopsy confirmed 90% infiltration of the marrow by malignant plasma cells (Multiple Myeloma).
CT of the spine confirmed a compression/pathological fracture of the L1 vertebra, as well as osteolytic lesions at L3 and L5.
Laboratory findings: elevated serum IgG 76.65 g/L, beta-2 microglobulin 20.3 mg/L, progressive normocytic anemia, and reduced reticulocytes.

Current Complaint: The patient reports being relatively stable between hospitalizations. No fever, weakness, night sweats, or bone pain. Appetite preserved. Normal bowel and urinary function. No active bleeding.

Previous Hospitalizations / Prior Treatment: During the previous two hospitalizations, the patient received chemotherapy without significant complications. He denies loss of body weight. Zometa was administered via rapid NaCl infusion.

Previous Admission Date: 10.06.2026, ordinary hospitalization, 5th cycle, CY HTA protocol.

During previous hospitalizations: The Hematology Board confirmed that according to the general assessment H-Tom protocol, the patient was reclassified to the VCD protocol.

CURRENT MEDICATIONS (Therapy in Use)

Betaserc 16mg - 1 tablet x 2 daily
Forxiga 10mg - 1 tablet x 1 daily
Altexurin 100mg - 1/2 tablet x 1 daily
Siofor 1000mg - 2 tablets x 1 daily
Enap 10mg - 1 tablet x 1 daily
Enap H 1x1
Byol 5mg - 1 tablet x 1 daily
Aspirin 100mg - 1 tablet x 1 daily
Vitamin B complex, Mg direct

Lab Panel (24.06.2026):

CRP: 22.8
WBC (Le): 6.4, ANC: 3.53, Lymphocytes: 1.30, Monocytes: 1.07, Eosinophils: 3.64
Hemoglobin (Hgb): 116, Hematocrit (Hct): 0.356, MCV: 97.8, Platelets (Tr): 268
TPP: 69, Albumin: 40, IgG: 15.13, IgM: 0.25, Free kappa light chains: 29.8, Free lambda: (result present)
Beta-2 microglobulin: 9.40

Reviewing the most recent activity parameters at this hospitalization onset in the summer months: urination regular, no abdominal pain, no alcohol consumption. No hemorrhagic symptoms. Appetite good, stool normal, no joint pain. No hemorrhagic signs.

PRESENT STATUS (STATUS PRAESENS)

Clinically conscious, oriented, afebrile, eupneic at rest. No signs of hemorrhagic bleeding. Heart sounds normal, lung sounds clear. Abdomen soft and non-tender with a superficial and deep palpation, normal bowel sounds. Ventral hernia present in the midline. Abdomen soft, no organomegaly. Extremities without edema.

EKG: Sinus rhythm, HR 75/min, left axis deviation, deep S in D3, ST-T without depression.

FINDINGS AND OPINION (Second Document - NALAZ I MIŠLJENJE)

Diagnoses:

C90.0 - Myeloma multiplex IIIB IgG lambda ISS III (Multiple Myeloma, advanced stage)
S32.0 - Pathological fracture of the lumbar vertebra, level L1
Infiltration of L3, L5 and the posterior part of thoracic vertebra Th9
E11.9 - Type 2 Diabetes Mellitus, non-insulin-dependent, without complications
I10 - Essential (Primary) Hypertension

Summary: A 70-year-old patient who was hospitalized in the Hematology Department (OB Prijedor) for investigation of hypercalcemia, progressive renal impairment, and multiple osteolytic bone lesions confirmed by skeletal scintigraphy. Bone marrow biopsy showed 90% infiltration by malignant plasma cells. CT of the spine confirmed a compression/pathological fracture of L1, and osteolytic lesions at L3 and L5 with open etiology. Lab values: serum IgG 76.65, beta-2 microglobulin 20.3, progressive normocytic anemia, reduced reticulocytes.

During previous hospitalizations (two cycles), the patient received therapy without major complications. No body weight loss. Zometa administered via rapid NaCl infusion. The Hematology Board confirmed, per the general H-Tom assessment, reclassification to the VCD protocol.

Previous admission: 10.06.2026, ordinary hospitalization, 5th cycle, CY HTA.

During the current hospitalization: The patient reports being stable. No fever. No weakness, pain in bones or joints. Appetite preserved. Normal urination, no abdominal pain. No hemorrhagic signs. Good stool.

Physical Exam: Conscious, oriented, afebrile, eupneic. Heart action regular, normal heart sounds, lung sounds clear without adventitious sounds. Abdomen normal to palpation, peristalsis present, liver and spleen not enlarged, soft, no deep tenderness, ventral hernia present, no organomegaly. Extremities without edema.

EKG: Sinus rhythm, HR 75/min, left axis, deep S in D3, ST-T without depression.

Lab (24.06.2026): CRP 22.8 | Le 3.53 | Ly 1.30 | Mono 1.07 | Er 3.64 | Hgb 116 | Hct 0.356 | MCV 97.8 | Tr 268

Physician: Dr. Snježana Opačić

In summary: This is a medical record for a 70-year-old man (Ljuban Jeftić) with advanced Multiple Myeloma (Stage IIIB, IgG lambda type, ISS III) complicated by a pathological spinal fracture at L1, spinal infiltration at L3/L5/Th9, Type 2 Diabetes, and hypertension. He is currently undergoing chemotherapy (VCD protocol, 5th cycle), with his next hospitalization scheduled for July 10, 2026.

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