karusmle
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a 67 yr old man comes for routiene health maintenence examination,she drinks one once of alcohol daily,her BP is 138/62,pulse is 76/min and regular,and respirations are 14/min.the lungs r clear to auscultation.the remainder of the examination shows no abnormalities.lab studies shows
hb 12.8
calcium 11.9
creatinine 0.8
phosphorus 2.8
total protein 6.5
albumin 4.2
inonised calcium 5.8 (n is 4.5 to 5.1)
which of the following is the most appropriate next step in management??
a.measurement of serum alkaline phosphatase activity
b.measurement serum parathyroid hormone
c.measurement of serum vitamin D level
d.serum and urine protein electrophoresis
e.x ray film of the chest
f.skeletal survery
g.bone scan
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| dr in trouble
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I will go for D, (multiple myeloma)
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| AAAAA
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d
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| MAZI
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old age , anemia, hyrercalcemia, bone pain, icrease ESR = suspitious to MM
D
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| jmn
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B is ans
If this is an inpatient, then D
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| MAZI
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dear jmn
you should know that increase or decrease in PTH lead to opposite direction of Ca & phosphor for example hypercalcemia & hypophosphatemia, in this case, the man has only hypercalcemia.
I believe that this is not the typical case and for better diagnosis we want more detail, what,s your oponion karusmle
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| karusmle
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my option is D
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| achilles
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i'll go for B. the phosphorus is not normal here. its low. normal levels are 3-4.5 mg/dl and calcium is elevated. so i'll go for B as the next step.
multiple myeloma is definitely a possibility but there is no h/o bone pain and there are not enough clues which point towards MM...also this pt has normal RFT's and elevation of BUN and creatinine from damage to the kidney because of immunoglobulins is fairly common. i dont deny that this could be MM but i though of it as a less likely possibility for this question.
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| an
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i agree with jmn and achilles with b.
3 clues why it's not multiple myeloma...1. hb is normal(considering its is a female patient), 2. as rightly pointed out creat is normal, 3. total protein is normal, as is the (total protein-albumin) fraction.
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| achilles
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wonderful an. thanks. you just make it so much more clear.
i did not think of the total protein aspect although i did realise that it was normal but could not put it together(even when i knew that total protein will be raised in MM !!!!) but now i'll never forget it. thanks.
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| sachida
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B is clear choice to me
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| sachida
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Majority of MM patient in old age presents with spontaneous fractures. This patients presentation pretty much excludes MM diagnosis
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| MAZI
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i agree with B
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