Clinicopathologic

Presentation
Bayron, Lenny
Dapanas, Paolo
Delmonte, Nicoli
Kho, Roscelie
Larrazabal, Amari
Mangubuat, Pierre
Mejos, Tricia
Ogario, Iris
Pacilan, Cielo
Perez, Jasmine
Siao, Kimberly
General Data
60 y.o.

Female
Chief Complaint

3 months
Fatigue
Body malaise

Given calcium
Past Medical History
Non-hypertensive

Non-diabetic

Non-asthmatic

No food and drug allergies

No previous hospitalizations
 PERSONAL AND
SOCIAL HISTORY

Nonsmoker

Non – alcoholic beverage drinker

 Physical Examination
GENERAL VITAL SIGNS SKIN HEENT

• Awake • BP: • Pale

100/60mmHg • Dry conjunctivae
• Conscious
• HR: 110bpm • Pale lips
• Not in
respiratory • RR: 31cpm
distress • Senile
• 02 sat : 94%
room air
 Physical Examination
CHEST/LUNGS ABDOMEN/
NECK CVS EXTREMITIES

• (+) rales on
• No right lower lung • NABS, soft,
lymphade field • Tachycardic nontender, no
nopathy
• Distinct Heart hepatospleno
• No wheezing megaly
Sounds
• Negative KPS,
strong pulses
 Summary of Important Findings

60 year old
Female Pale
Tachycardic
Back pain palpebral
(110 bpm)
Fatigue conjunctiva,
Tachypneic
Body pale lips
(31 cpm)
malaise (+) rales RLL
field
Clinical Impression

MULTIPLE MYELOMA
 Differential Diagnosis
MUSKULOSKEL
TRAUMA DEGENERATIVE
ETAL

• FRACTURES • LUMBAR DISC • COMPRESSIO

SECONDARY DISEASE N FRACTURE
TO FALL / SEC TO
TRAUMA OSTEOPORO
SIS
 Differential Diagnosis
NEOPLASTIC INFECTIOUS

• METASTATIC • EXTRA
BONE PULMONARY
DISEASE TB OF THE
WITH AN BONE /
UNKNOWN VERTEBRA
PRIMARY (POTT’S
DISEASE)
Knowledge Gap

Is there a history of trauma or fall?

 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 32, Page 162

 Knowledge Gap

Are there abnormalities in: gait, vision,

balance, hearing, cognition, or lower extremity
strength?
Does the patient use assistive devices?
 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 32, Page 162

 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 32, Page 164-165

 Differential Diagnosis
MUSKULOSKEL
TRAUMA DEGENERATIVE
ETAL

• FRACTURES • LUMBAR DISC • COMPRESSIO

SECONDARY DISEASE N FRACTURE
TO FALL / SEC TO
TRAUMA OSTEOPORO
SIS
 Knowledge Gap

What are the characteristics of the back pain

elicited in the patient?
 Harrison’s Principles of internal Medicine, 19th Edition

Delineating the type of pain reported by the patient is an essential first step.

Local pain?
Pain referred to the back?
Pain of spine origin?
Radicular pain?
Pain associated with muscle spasm?

Chapter 22, Pages 111-

112
Knowledge Gap

What is the patient's weight?

 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 22, Page 115

Knowledge Gap

Was there any motor or sensory deficits?

 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 19, Page 95

 Differential Diagnosis
MUSKULOSKEL
TRAUMA DEGENERATIVE
ETAL

• FRACTURES • LUMBAR DISC • OSTEOPORO

SECONDARY DISEASE TIC
TO FALL / FRACTURE
TRAUMA
 Knowledge Gap

Does the patient have any skeletal deformity?

Harrison’s Principles of internal Medicine, 19th Edition
Knowledge Gap

Is there decrease in patient’s height?

Harrison’s Principles of internal Medicine, 19th Edition
 Knowledge Gap

Was there history of lifting heavy objects or

performing strenous activities?
 Harrison’s Principles of internal Medicine, 19th Edition

Pags 462e-7
 Differential Diagnosis
MUSKULOSKEL
TRAUMA DEGENERATIVE
ETAL

• FRACTURES • LUMBAR DISC • OSTEOPORO

SECONDARY DISEASE TIC
TO FALL / FRACTURE
TRAUMA
 Knowledge Gap

Is there a history of cancer or a preexisting benign

condition?
 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 119e
 Knowledge Gap

If yes:
Is there a history of radiation therapy?
 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 119e
 Knowledge Gap

Is there any pain and swelling over the affected

area?
 Harrison’s Principles of internal Medicine, 19th Edition

Chapter 119e
 Knowledge Gap

Was breast examination performed? What were

the findings?
Bate’s Guide ro Physical Examination and History Taking, 11th
Edition
 Differential Diagnosis
NEOPLASTIC INFECTIOUS

• METASTATIC • EXTRA
BONE PULMONARY
DISEASE TB OF THE
WITH AN BONE /
UNKNOWN VERTEBRA
PRIMARY (POTT’S
DISEASE)
Knowledge Gap

Was a recent Chest Xray taken?

 Harrison’s Principles of internal Medicine, 19th Edition

Postprimary TB is most accurately termed Adult-type TB because it may

result from endogenous reactivation of distant LTBI or recent infection. It
is usually localized in the apical and posterior segments of the upper lobes,
where the substantially higher mean oxygen tension favors mycobacterial
growth, thus showing an abnormal finding in the apical or upper lobes in
the chest radiograph result.

Chapter 202, Page 1108

 Knowledge Gap

Is the patient showing other signs of

musculoskeletal problems such as altered posture,
specifically kyphosis? Numbness and tingling
sensation on lower extremities? Or pain and
swelling on the hips or knee joints?
 Harrison’s Principles of internal Medicine, 19th Edition

TB of the bones and joints is responsible for 10% of extrapulmonary cases. In bone and joint disease,
pathogenesis is related to reactivation of hematogenous foci or to spread from adjacent paravertebral lymph
nodes. (Because bacilli are usually transported by macrophages to regional lymph nodes and from there they
gain access to the central venous return; from there they reseed the lungs and may also disseminate beyond
the pulmonary vasculature throughout the body via the systemic circulation.) Weight bearing joints are most
commonly affected (spine 40%, hips 13%, knees 10%). Spinal TB Pott's disease or tuberculous spondylitis often
involves two or more adjacent vertebral bodies. The lower thoracic and upper lumbar vertebrae are usually
affected in adults. From the anterior superior or inferior angle of the vertebral body, the lesion slowly reaches
the adjacent body, later affecting the intervertebral disk. With advance disease collapse of vertebral bodies
causes a kyphotic posture.

Chapter 202, Pages 1109-

1110
 Differential Diagnosis
NEOPLASTIC INFECTIOUS

• METASTATIC • EXTRA
BONE PULMONARY
DISEASE TB OF THE
WITH AN BONE /
UNKNOWN VERTEBRA
PRIMARY (POTT’S
DISEASE)
 Work-up
1. CBC 12. Bone density scan
2. Urinalysis 13. Serum protein
3. CXR PA view electrophoresis
4. Skeletal survey
5. Thoracolumbar xray
6. Serum calcium
7. Serum creatinine
8. Alkaline
phosphatase
9. BUN
10. AFB smear
11. ESR
 Clinical Impression

• MULTIPLE MYELOMA
• CAP – MR
MULTIPLE MYELOMA
 Etiology
Unknown

Theories

Radiation exposure

Occupation

Chromosomal alterations

Interleukin 6
Incidence and prevalence

Median age: 69
Uncommon: <40 y.o.
M>F
Morbidity: 24,050 new cases in 2014
Mortality: 11,090 cases in the U.S.
Highest: African Americans and
Pacific Islanders

Intermediate: Europeans and North

American whites

Lowest: developing countries

including Asia
Pathophysiology
Clinical Manifestations

Bone pain
Characteristic
“punched
out” lesions

Hypercalcemia

Bony lesions
palpated in the
skull, clavicles
and sternum
 pneumonias

Susceptibility
to infections
pyelonephritis

Renal failure
in 25% of hypercalcemia
patients
replacement of
normal marrow
by expanding
tumor cells
Normocytic
inhibition of and
hematopoiesis normochromic
by tumor
factors anemia

reduced
production of
erythropoietin
by the kidney
Pathogenesis
Diagnostic criteria
Workup
Prognosis
Treatment
Thank you