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A 78-year-old woman is admitted to the hospital because of a fever, productive cough, and a chest x-ray demonstrating right lower lobe consolidation. Her past medical history is significant for seasonal allergies. She has been taking estrogen/progesterone replacement since menopause 19 years ago and occasional acetaminophen for headaches. The patient lives alone at her home and she does not drink alcohol or smoke. Review of systems is significant for weakness attributed to œold age". On the day prior to discharge, a repeat chest x-ray shows the pneumonia to be resolving. An incidental note is made of severe osteoporosis involving all of the bones visualized on the film. Vital signs are temperature 38.8 C (101.8 F), blood pressure 100/50 mm Hg, pulse 90/min, and respirations 10/min. Physical examination is significant only for decreased breath sounds at the right lung base. The patient is neurologically intact and wants to return home. Laboratory studies show a leukocyte count 15,000/mm3, hematocrit 28%, and platelets 150,000 mm3. The next step in the management of this patient is to

A. discharge her and do a bone marrow biopsy as an outpatient


B. discharge her and send her for a bone scan as an outpatient


C. discharge her and order serum protein electrophoresis as an outpatient


D. do a bone marrow biopsy before discharge


E. order a bone scan and serum protein electrophoresis before discharge

ee

E. order a bone scan and serum protein electrophoresis before discharge?

why ?
r u thinking of multiple myeloma
But bone scan has low sensitivity for myeloma lesions and has no role in its workup

)

I'm thinking in osteoparosis for other causes also, although she is hormonal Rx.

EEE ... diffuse osteolysis, severe infection and un explained anemia (weakness can be due to anemia) in an elderly ... rule out multiple myeloma

ANS: C

The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma (IMP POINT)

Bone scan has a low sensitivity for myeloma lesions and has no role in its workup. Do not confuse a bone survey which is a series of x-rays evaluating all of the bones with a bone scan which is a nuclear medicine scan.

This patient is presenting to the hospital with pneumonia. The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma. The clinical signs are nonspecific constitutional symptoms such as general malaise or weakness. Laboratory data includes anemia, an elevated creatinine from secondary renal dysfunction, and elevated IgA and IgG levels. The first priority is to treat the patient for pneumonia and return the patient to her normal life as soon as possible. The next priority is to evaluate for multiple myeloma and the family of disorders involving monoclonal proliferation. This would include a serum protein electrophoresis (SPEP), a plain radiographic bone survey, and an assessment of renal function. Patients that are asymptomatic with no significant anemia, pathological fractures, or renal failure do not require treatment.

but bone scan can detect pathological fractures in multiple myeloma though it is not useful for diagnosing myeloma as such.

) nice thx