3

rd

CPC
Group 7
PERTINENT DATA FROM THE HPI,
COURSE IN THE WARDS AND
LABORATORY RESULTS

DIFFERENTIAL
DIAGNOSIS

WORKING
IMPRESSION/DIAGN
OSIS

PATHOPHYSIOL
OGY

DIAGNOSIS
J.A., A 56 YEAR OLD MALE, OFFICE
WORKER, FROM LAS PINAS, WAS
ADMITTED FOR THE FIRST TIME TO
PGH ON MAY 18, 1987 FOR
PLEURITIC CHEST PAIN, BACK
ACHES AND KNEE JOINT PAINS.
 4 MONTHS PRIOR TO ADMISSION

DEVELOPED HOARSENESS OF VOICE

 1 MONTH PRIOR TO ADMISSION

FIRST BLACK COLORED STOOLS WAS NOTED

2 WEEKS PRIOR TO ADMISSION

SLURRING OF SPEECH
BILATERAL KNEE JOINT PAINS WITHOUT
REDNESS NOR SWELLING
LOW BACK PAINS NOT AGGRAVATED BY MOTION
]
ANTERIOR CHEST PAINS
4 DAYS PRIOR TO ADMISSION

SOUGHT CONSULT IN A NEARBY

HOSPITAL
TREATED WITH ANTI-KOCHS
MEDICATION AND PENICILLIN
TRANSUFUSED 4 UNITS OF BLOOD FOR
PALLOR
(-) BONE SURVEYS
(+) GASTRITIS [BY BARIUM SWALLOW]
WAS REFERRED TO PGH FOR FURTHER
WORK-UP AND MANAGEMENT WHEN
BONE PAINS BECAME PERSISTENT
 UPON ADMISSION

ERSONAL AND SOCIAL HISTORY

HALF A CASE OF BEER 3X/WEEK FOR THE PAST 40
YEARS
30 PACK YEARS OF SMOKING
PHYSICAL EXAMINATION
LAPSES OF DROWSINESS WITH SLURRED SPEECH
BP: 130/80, RR: 28/MIN
ICTERIC SCLERAE
DRY TONGUE AND MUCOSA
(+) TENDERNESS ON PALPATION OF ANTERIOR RIBS
AND STERNUM
(+) ASTERIXIS/TREMORS
CRANIAL NERVE VII: SHALLOW LEFT NASOLABIAL
FOLD
MENINGEAL: SLIGHT NECK RIGIDITY WITH PAIN
RADIATING TO THE BUTTOCKS
UPON ADMISSION

DEVELOPED RESPIRATORY DISTRESS

WITH PRODUCTION OF RONCHI AND
RALES OVER THE LUNG FIELDS
DEVELOPED SLEEP-WAKE
DISTURBANCES WITH DISORIENTATION
AND MELENA
WAS GIVEN ANTI-HEPATIC
ENCEPHALOPATHY REGIMEN
INTUBATED FOR RESPIRATORY FAILURE
AND GIVEN ANTI-BIOTICS
TRANSFUSED 8 UNITS FRESH WHOLE
BLOOD
DAY 2

FECALYSIS: (++++) OCCULT BLOOD

DAY 4

CHEST BUCKY: BREAK IN ENTIRE

POSTERIOR RIB WITH FOCAL LYTIC
REACTION
PEURAL BASED DENSITY ADJACENT TO
LATERAL ASPECT OF THE RIGHT 3RD
AND 4TH RIBS
DAY 6

ENDOTRACHEAL ASPIRATE C/S:

MODERATE GROWTH OF KLEBSIELLA
 DAY 7

CHEST X-RAY:
(+) PNEUMONIA
MINIMAL PTB
LYTIC RIB LESION
LEURAL BASED MASS AT LEFT MIDDLE LUNG FIELD
DAY 9

ENDOTRACHEAL ASPIRATE C/S: (+) E.

COLI
 DAY 10

ULTRASOUND:
MILD HEPATOMEGALY
ASCITES

CONTINUED ON/OFF COFFEE GROUND

UPPER GASTROINTESTINAL BLEEDING
AND MELENA
WAS GIVEN ANTACID + H2 BLOCKERS
WITH BLOOD TRANSFUSION
CONTINUED POOR VENTILATORY
EFFORT AND COULD NOT TOLERATE
WEANING FROM THE RESPIRATORY
DAY 16

ENDOTRACHEAL ASPIRATE C/S: (+)

VERY FEW COLONIES OF
PSEUDOMONAS AEROGINOSA
DAY 20

ENDOTRACHEAL ASPIRATE C/S: (+)

PSEUDOMONAS AEROGINOSA
DAY 21

ELEVATED ALKALINE AND ACID

PHOSPHATASE
SERUM ELECTROPHORESIS: WIDE
BASED POLYCLONAL GAMMOPATHY
BONE ASPIRATE: MILD PLASMACYTOSIS
[7.2% PLASMA CELLS]
DAY 21

DEVELOPED HYPOTENSION WITH LOW

CVP FLUID THERAPY AND DOPAMINE
WERE GIVEN
CONTINUED ON/OFF GI BLEEDING
BLOOD TRANSFUSION WAS
ADMINISTERED
DEVELOPED PULMONARY
HEMORRHAGE, BLEEDING FROM
TRACHEOSTOMY TUBE AND BLOOD
OTORRHEA IV BICARBONATE WAS
GIVEN
DAY 24

DIALYSIS WAS INITIATED DUE TO POOR

URINE OUTPUT AND INCREASING
CREATININE LEVELS
832 UMOL/L CREATININE
DAY 28

URINE C/S: 100,000 COLONIES OF

CANDIDA sp./ml.
DAY 29

CREATININE WAS DECREASED TO 162

UMOL/L SENSORIUM NOT IMPROVED
PATIENT WENT INTO STUPOR AND
COMA CARDIOPULMONARY ARREST
AND UNRESPONSIVE TO
CARDIOPULMONARY RESUSCITATION
 CBC
NORMAL
DAY 1 DAY 2 DAY 9 DAY 25 DAY 28
VALUES
Hb 140-175
58 28 139 119 83
(gm/L) g/L

Hct 0.18 0.10 0.42 0.36 0.25 0.41-0.50

WBC x 4.4-
12.5 8.4 7.9 17.5 3.4
109/L 11.3X109/L
Segment
77 85 89 80 - 56
ers
Lymphocy
22 13 9 16 - 34
tes
150,000-
Platelets
250 - - 200 80 450,000/
x 109/L
L
 PROTIME
NORMAL
PROTIME DAY 7 DAY 20 DAY 21
VALUES

Control 12 sec 13 sec

15.7 sec 20.7 sec

Patient 10-13 sec.

Activity 0.54 0.24

CT 8 min 5-8min N

BT >10 min 2-8min

50% in 1 completed
CRT
hour in 4 hours
 NORMAL
DAY 1 DAY 21 DAY 24 DAY 27 DAY 29
VALUES
3.9 - 7.8
RBS 7.68 - - - -
mmol/L
2.9 - 8.2
BUN 5.06 5.57 17.06 14.29 6.93
mmol/L
53 106
CREAT 90 96 832 153 162
mmol/L
136 142
Na 140 140 140 130 128
mmol/L
3.8 5.0
K 4.2 3.2 2.6 <2.5 < 2.5
mmol/L
4 4.8
Ca 3.13 - - -
mg/dL

TP 76 60 78 g/L

Alb 64 32 45 g/L

Glob 12 18 23 35 g/L

DB 1.72 3.42 < 0.3 mg/dL

0.1 1.0
IB 2.04 3.42
mg/dL

Alk Phos 96 205 20 130 U/L

2.2 10.5
Acid Phos - 3.5
U/L

SGOT 42.6 3 BLOOD CHEMISTRIES 8 33 U/L

PERTINENT DATA FROM THE HPI,
COURSE IN THE WARDS AND
LABORATORY RESULTS

DIFFERENTIAL
DIAGNOSIS

WORKING
IMPRESSION/DIAGN
OSIS

PATHOPHYSIOL
OGY

DIAGNOSIS
 PERTINENT
DATA
NON - NEOPLAS
NEOPLASTIC TIC
NON- INFECTIO BENIG MALIGNA
INFECTIOUS US N NT
MYOCARDI TUBERCUL FIBROUS PROSTATIC
AL OSIS DYSPLA CA
INFARCTIO LEPTOSPIR SIA HEPATO
N
HYPOTHYROID OSIS CELLULAR
ISM OSTEOMYEL CA
ITIS LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
 NON-
INFECTIOUS
MYOCARDI
AL
INFARCTIO
N
HYPOTHYROID
ISM
 NON-
INFECTIOUS
MYOCARDI
AL
INFARCTIO
N
HYPOTHYROID
ISM
 PERTINENT
DATA
NON - NEOPLAS
NEOPLASTIC TIC
NON- INFECTIO BENIG MALIGNA
INFECTIOUS US N NT
MYOCARDI TUBERCUL FIBROUS PROSTATIC
AL OSIS DYSPLA CA
INFARCTIO LEPTOSPIR SIA HEPATO
N
HYPOTHYROID OSIS CELLULAR
ISM OSTEOMYEL CA
ITIS LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
INFECTIO
US
TUBERCUL
OSIS
LEPTOSPIR
OSIS
OSTEOMYEL
ITIS
INFECTIO
US
TUBERCUL
OSIS
LEPTOSPIR
OSIS
OSTEOMYEL
ITIS
INFECTIO
US
TUBERCUL
OSIS
LEPTOSPIR
OSIS
OSTEOMYEL
ITIS
 PERTINENT
DATA
NON - NEOPLAS
NEOPLASTIC TIC
NON- INFECTIO BENIG MALIGNA
INFECTIOUS US N NT
MYOCARDI TUBERCUL FIBROUS PROSTATIC
AL OSIS DYSPLA CA
INFARCTIO LEPTOSPIR SIA HEPATO
N
HYPOTHYROID OSIS CELLULAR
ISM OSTEOMYEL CA
ITIS LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
 BENIG
N
FIBROUS
DYSPLA
SIA
 PERTINENT
DATA
NON - NEOPLAS
NEOPLASTIC TIC
NON- INFECTIO BENIG MALIGNA
INFECTIOUS US N NT
MYOCARDI TUBERCUL FIBROUS PROSTATIC
AL OSIS DYSPLA CA
INFARCTIO LEPTOSPIR SIA HEPATO
N
HYPOTHYROID OSIS CELLULAR
ISM OSTEOMYEL CA
ITIS LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
 MALIGNA
NT
PROSTATIC
CA
HEPATO
CELLULAR
CA
LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
MA
 MALIGNA
NT
PROSTATIC
CA
HEPATO
CELLULAR
CA
LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
MA
 MALIGNA
NT
PROSTATIC
CA
HEPATO
CELLULAR
CA
LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
MA
 MALIGNA
NT
PROSTATIC
CA
HEPATO
CELLULAR
CA
LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
MA
 MALIGNA
NT
PROSTATIC
CA
HEPATO
CELLULAR
CA
LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
MA
 MALIGNA
NT
PROSTATIC
CA
HEPATO
CELLULAR
CA
LUNGS-
SMALL
CELL CA
PRIMAR
Y
BONE
METASTA
CA
SES
MULTIPL
E
MYELO
MA
PERTINENT DATA FROM THE HPI,
COURSE IN THE WARDS AND
LABORATORY RESULTS

DIFFERENTIAL
DIAGNOSIS

WORKING
IMPRESSION/DIAGN
OSIS

PATHOPHYSIOL
OGY

DIAGNOSIS
MULTIPLE MYELOMA
PERTINENT DATA FROM THE HPI,
COURSE IN THE WARDS AND
LABORATORY RESULTS

DIFFERENTIAL
DIAGNOSIS

WORKING
IMPRESSION/DIAGN
OSIS

PATHOPHYSIOL
OGY

DIAGNOSIS
 56 YEAR OLD MALE

CHROMOSOMAL ALTERATIONS:
13q14, 17p13, t(11;14) (q13;q32), t(4;14) (p16;q32)

DEVELOPMENT OF INDUCTION OF CYTOKINES RAS/RAF/MITOGEN-

MALIGNANT PLASMA BLAST
(IL-6, IGF-1, VEGF, SDF-1a)
ACTIVATED PROTEIN KINASE
[MM CELLS] P13-K/Akt, PROTEIN KINASE C

[VIA CELL SURAFACE

ADHESION MOLECULES]
BINDS TO BONE MARROW
STROMAL CELLS AND
EXTRACELLULAR MATRIX

UNCONTROLLED MM CELL GROWTH

 UNCONTROLLED MM CELL GROWTH

FORMATION OF PRODUCTION OF PRODUCTION OF

PLASMACYTOMAS PARAPROTEIN BENCE JONES
[MM] [M-PROTEIN] PROTEIN***

- REDUCED GFR
- POOR URINE OUTPUT
HYPERVISCOSITY
- CREATININE
- UNRESPONSIVE TO DIURETICS

SUSCEPTIBILITY TO ACUTE RENAL

BACTERIAL INFECTIONS FAILURE
 FORMATION OF
PLASMACYTOMAS [MM]

COMPRESSION OF TUMOR RELEASE OF

BONE TISSUE, BONE MARROW INFILTRATION IL-6, TNF
AND NERVE ENDINGS
PLEURITIC CHEST PAIN, BACK PAIN,
BILATERAL KNEE JOINT PAIN]
RECRUITMENT AND
ACTIVATION OF
OSTEOCLASTS
CRICOID CARTILAGE INVOVLMENT
[HOARSENESS OF VOICE]

OSTEOLYTIC LESIONS
[BREAK IN THE ENTIRE
POSTERIOR RIB WITH
NEUROLOGIC SYMPTOMS DUE TO FOCAL LYTIC LESIONS]
CORD COMPRESSION OR
BONE COLLAPSE
SLURRING OF SPEECH, 4/5 MUSCLE
WEAKNESS, SHALLOW NASOLABIAL
FOLD, SLIGHT NECK RIGIDITY]
 TUMOR REPLACEMENT
INFILTRATION OF HEMATOPOIESIS
NORMAL
MARROW
WBC MEGAKARYOCYTES RBC
LEUKOPENIA PLATELETS [ANEMIA]
[ SUSCEPTIBILITY TO THROMBOCYTOPENIA
BACTERIAL INFECTIONS] [ SUSCEPTIBILITY TO
BLEEDING]
SEPSIS

PNEUMONIA
LOW CVP, DISSEMINATED
HYPOTENSIONINTRAVASCULAR PULMONAR
DISORDER Y
TUBERCUL
OSIS
GASTRITIS
PULMONARY HEMORRHAGE
BLEEDING FROM TRACHEOSTOMY TUBE HEMATOCHEZIA
SHOCK BLOOD DIARRHEA
MILD HEPATOMEGALY
ICTERIC SCLERAE MELENA
PERTINENT DATA FROM THE HPI,
COURSE IN THE WARDS AND
LABORATORY RESULTS

DIFFERENTIAL
DIAGNOSIS

WORKING
IMPRESSION/DIAGN
OSIS

PATHOPHYSIOL
OGY

DIAGNOSIS
MULTIPLE MYELOMA
END