Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in a haematology clinic. Your next patient is Luffy D Piece – a 56-year-old man who has been referred by General Practice using a 2-week wait referral – querying haematological cancer. This patient presents with easy bruising with a urine test showing "light chain proteins". Please take a history and perform an appropriate examination.
Patient History:
Your name is Luffy D Piece – 56-year-old gentleman – retired.
You came in today due to bruising around the surface of your tummy and arms, which started one month ago. Since then, this has been gradually getting worse. You are not bleeding anywhere else as far as you are concerned e.g. stool, urine…etc.
You also noticed worsening back pain behind your chest – describing it as a constant dull ache – a 5/10 pain score that sometimes can wake you up at night. This is not the only thing that is causing you trouble falling asleep! You also have night sweats and have been waking up in the middle of the night to urinate more often than usual. You always feel thirsty.
You feel tired, but you think this is because of the poor sleep you have been getting – averaging only around 3-4 hours a night. You have lost a bit of weight in the past month, around 2 kg. However, you have a low appetite and haven’t eaten the same amount as usual. You are constipated and currently taking a laxative you got from the chemist, which only improved slightly.
No changes in vision. No headache, No dizziness. No confusion. No shortness of breath. No chest pains. No fever.
Ideas, Concerns, Expectations:
You have no idea what is going on. Everything feels so weird. You do not feel like yourself anymore - you have never experienced anything like this. You are concerned as your GP mentioned "cancer" needs to be ruled out. You do not want to die yet! You hope to find out what is going on and get treatment as soon as possible.
Past Medical History:
Heart Failure, Hypercholesteremia, Obesity
Drug History:
Furosemide, Movicol (laxative)
Family History:
Hypertension
Social History:
Retired but used to work as an on-site petroleum chemical engineer, ex-smoker, rarely drinks alcohol, lives alone in a Bungalow, independent.
Examination Findings:
Random patterned bruising around the surfaces of arms and abdomen with no active bleeding on general inspection.
Signs of dehydration- reduced skin turgor, increased CRT, dry mucous membrane.
Palmar erythema.
Mild pitting oedema at ankles.
Calves are soft and non-tender.
Spinal tenderness at the thoracic region
No other abnormal findings otherwise on examination.
Differentials:
Multiple Myeloma (MM)
Monoclonal gammopathy of undetermined significance (MGUS)
Solitary plasmacytoma (due to localised bone pain)
Amyloid light-chain (AL) amyloidosis
B-cell non-Hodgkin’s lymphoma
Investigations:
Bedside:
Observations
Urine electrophoresis to detect free monoclonal light chain paraprotein (Bence Jones Protein)
Bloods:
FBC (normocytic anaemia)
Bone Profile (hypercalcaemia, hyperalbuminemia)
U&Es (can show impaired renal function and dehydration)
ESR/plasma viscosity (raised)
Coagulation screen (bruising/bleeding)
Serum-free light chain assay (raised)
Serum immunoglobulin (non-myelomatous Ig can be suppressed, but myelomatous Ig is raised)
Serum protein electrophoresis (shows the raised type of myeloma proteins, especially in active/smouldering MM)
Serum beta2-microglobulin (for staging MM)
Serum/urine immunofixation (identify paraprotein Ig subtype in MM)
LDH (higher levels indicate extensive disease)
Hba1c/ glucose (due to polyuria/polydipsia/weight loss)
Hepatitis screen / HIV screen before starting myeloma treatment
Imaging:
Skeleton Survey
MRI/CT (full body)
Consider XR when indicated– patchy/ thin bones, osteolytic/punched-out lesions, pathological fractures, collapsed vertebral body, raindrop skull…etc.
Special tests:
Bone marrow aspirate and biopsy with plasma cell phenotyping (confirm the diagnosis of myeloma and assess monoclonal plasma cell infiltration)
Consider cytogenetic analysis and fluorescence in situ hybridisation (FISH) (prognostic test with therapeutic implications)
Consider mass spectrometry (detects the presence of a paraprotein)
Management: