miercuri, 18 mai 2011

Acte iesire din spital


TRANSLATION FROM ROMANIAN

Translation from Hungarian:


SIMMELWEIS UNIVERSITY
OPHTHALMOLOGICAL CLINIC
1085 BUDAPEST MARIA ST. 39
R.O.P. AMBULANCE
Director: Professor NEMETH JANOS
Tel: 2660513 / 54589

                                                                                                                             

AMBULATORY TREATMENT CHART

Patient’s Name: FLOREA ANEMONA
Maiden Name: FLOREA ANEMONA
Date of Birth: July 26, 2009
Mother’s Name: FLOREA CRISTINA
Residence: ROMANIA

Hospital admission date: September 8, 2010 08:14

Referral No: 014020529
Code: 00001727627
Patient Number: 9024595
Registration Number: 00000254


Health condition on:
January 7, 2010, at 10:12

The patient (born prematurely in the 31-32th pregnancy week and weighing 1,620 grams) has been referred from Romania, where she had been examined by Romanian ophthalmologists in Timisoara and diagnosed with AO / Indirect Ophthalmoscopy  AO / Retinopathies prematurity stage 5 Retinoschisis (Retinal Splitting).
Since she was born in 2009 through September 2009 she was hospitalized at NIC Timisoara (her father used an interpreter to talk to us).

After dilatation : white tissue (illegible in Hungarian)
B-scanning: Retinopathy with closed funnel in the background.
                    AXL together with the eyelid, approx. 16 mm (illegible in Hungarian)

Conclusions: no amelioration may be expected through the envisaged (illegible in Hungarian) surgical intervention.
The patient’s parents are asked to call dr. Recsan on the telephone on January 13 – dr. Recsan shall be informed until then.

January 14, 2010, at 14:57:
- idem -
Conclusions: no amelioration may be expected through the envisaged (illegible in Hungarian) surgical intervention.

September 8, 2010, at 12:51:
Stou microphthalmus; heavy dilatable eyelid; background adherence; gray retrolental plate.
 
Ultrasonography: retina disjunction in the form of a closed funnel in half the background; right eye: clean subretinal space; left eye: spontaneous flux in the subretinal space, generated by punctiform echoresources with low reflection.

Conclusions: no amelioration may be expected through the envisaged (illegible in Hungarian) surgical intervention.
September 8, 2010

Zsuzsanna Recsan – MD, Associate professor
Seal & signature.


I, the undersigned Bakk Miklos, in my capacity as a certified translator with  Authorization # 3153/2000 Deparment of Justice  certify herewith that, to the best of my abilities, the above translation is accurate and true to the text of the authentic document in Hungarian submitted to me for translation purposes.

Translator
Stamp & signature






I, the undersigned Vlad CINGHITA, in my capacity as a certified translator in English, French and German certify herewith that, to the best of my abilities, the above translation is accurate and true to the text of the authentic document in Romanian submitted to me for translation purposes.

Translator (Authorization # 1654/March 1999, granted by the Department of Justice)





TRANSLATION FROM ROMANIAN

LOUIS TURCANU CHILDREN’S EMERGENCY CLINICAL HOSPITAL TIMISOARA
Premature Newborns Neonatology


HOSPITAL RELEASE CERTIFICATE

Observation Chart No. 10031
Patient’s personal identification number: 6090726351579


Name: FLOREA; First Name: ANEMONA
Residence: Sanovita no. 309, Timis

Admission Date: July 26, 2009

Release Date: September 11, 2009


Diagnosis:
  1. Premature brith grade II
  2. Acute hypoxia Retropartum
  3. Hemorrhage 2nd grade
  4. Prolonged neonatal jaundice 
  5. illegible
  6. Anemia caused by premature birth and illness 

Anamnesis: Newborn resulted from a GIII, PII pregnancy; spontaneous birth; body weight at birth: 1,600 g. Hospitalized after referral from the Lugoj Municipal Hospital Maternity.

Health condition when hospitalized: general health condition: influenced; cold limb extremities, acrocyanosis, overlapped sutures, incomplete archaic reflexes and illegible

Admitted to the ICU from July 26, to August 4, 2009.

Biological and paraclinical tests:

Hemoleukogramm
July 26
August 19
August 28
Hemoglobin g/l
17.7
14.4
13.8
Red blood cells
5270000
4620000
4630000
Thrombocytes / mm3  
281000
500000
435000
Leukocytes/ mm3
20000
26780
15040


Ionogram
July 26
August 19
Na mmol/l
131
140
K mmol/l
7
6
Ca mmol/l
1.22
1.32


July 26
August 10
TGP U/L
11
15
TGO U/L
67
23
LDH U/L
647
-
Glycemia mmol/l
4.54

Protein g/l
48.8

GGT U/L
47



July 30
August 19
BD mmol/l
10.70
16,83
BI mmol/l
211.46
354
Urea  mmol/l
3,19

Creatinine  mmol/l
52

FAL

337
Coombs test

Negative

Astrup
pH
7,34
PCO2
30,9
PO2
42,1
BE
-9,4


CRP: (26.07) 0.64 mg/l ; (19.08) 2.24 mg/l

Haemoculture:
Urine culture: 3.08 sterile
Pharyngeal exudates: July 27 -  MSDG
Ocular secretions: July 27 MSDG
Nose secretions: July 27. MSDG
RX: August 1 – Heart, lung – according to age
Transfontanelar ultrasonography: illegible
Heart ultrasonography: illegible
NPI test illegible

Evolution and health condition when released from hospital:
Weight: 2,500 g
Good general health condition; teguments and mucous membranes normally colored; 3rd degree systolic heart murmur; lungs – normal relations; soft abdomen.

Therapy performed in the hospital and medication: Tienam, Cefort, Gentamicina, Linezolid, Vitamin K1, Etamsilat
Recommendations: Calcium gluconate, Miofilin, Oxigen Therapy, Colir Cloramphenicol
Newborn under neurological risk.
The patient is to show up for heart tests on September 24, 2009.


RECOMMENDED THERAPY:


Morning
Noon
Evening
Tanakan syrup
0.1   ml
+ 2 ml tea
-
-
Ferrum Haussmann
5 drops
-
-
Polyvital
3 drops
3 drops
3 drops
Vigantol
3 drops
-
-

Date: September 11, 2009

Department Head
Dr. Boia Marioara – Lecturer Ph. D
Stamp & signature

Curing MD
Dr. Boia Marioara – Lecturer Ph. D
Stamp & signature

Resident MD
Dr. Sipos Lavinia
Stamp & signature

=====================================================
 

TRANSLATION FROM ROMANIAN
===============================================================


Dr. Dumitru Popescu Clinical Hospital of Timisoara


MEDICAL LETTER


Dear Colleague

We hereby inform you that your patient FLOREA ANEMONA, born on July 26, 2009, was examined by our staff in January 6, 2010.

Diagnosis: AO / Indirect Ophthalmoscopie  
                   AO / Retinopathies prematurity stade 5 Retinoschisis (Retinal Splitting)

Recommendations: Emergency checkup in a specialized clinic in vitreoretinian surgery.

Date: January 6, 2010          

Seal and signature:
Dr. FLORINA STOICA
Specialist MD Ophthalmology

==============================================================

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