LBP susp.

Multiple
Myeloma
Made Minarti Witarini Dewi
dr. Pande Putu Ayu Patria Dewi, Sp.PK
25 Februari 2019
HISTORY TAKING
.
Mrs. S, F, 49 y.o
Chief Complaint :
-Pain on right hipbone since a couple days ago before
admission
Present History Illness:
- Pain on right hipbone
- Tiredness
- Dizziness
- History of nausea,vomitting,bleeding denied
2
 Past History Illness:
- DM, Heart disease, Trauma denied
- CKD (2 months ago)

3
 PHYSICAL FINDINGS

Vital Sign Generally Status Abdomen : flat,

normoactive bowel
sounds, no
BP = 100/60 mmHg Head/neck : a-/ i-
palpable liver and
Pulse = 84 bpm Chest: spleen
RR= 20 times/mnt -Heart : S1S2 Extremities :
T = 36° C single, m-, g- warm, edema -
-Lung : ves/ves,
rh -/-, wh -/-

4
LABORATORY
FINDINGS

5
CBC Parameter 7/2/19 8/2/19 10/2/19 14/2/19 Reference
WBC 5.66 4.69 0.76 0.49 4.1 - 11.0 x 103/µL
Neu 79.51 75.17 43.11 9.27 47.00 - 80.00 %
Lym 18.33 22.66 51.76 75.00 13.00 - 40.00 %
Mono 1.76 1.96 3.81 13.15 2.0 - 11.0 %
Eos 0.06 0.05 0.15 2.37 0.0 - 5.0 %
Baso 0.34 0.16 1.17 0.22 0.0 - 2.0 %
RBC 1.17 1.26 1.87 3.00 4.5 - 5.9 x 106/µL
HGB 3.26 3.46 4.86 8.67 13.5 - 17.5 g/dL
HCT 9.77 10.34 15.68 23.79 41.0 - 53.0 %
MCV 83.75 81.99 83.99 81.29 80.0 - 100.0 fL
MCH 27.94 27.43 26.03 28.89 26.0 - 34.0 pg
MCHC 33.36 33.46 30.99 36.43 31 - 36 g/dL
RDW 11.60 12.19 12.04 11.86 11.6 - 14.8 %
PLT 2.66 2.87 43.89 14.42 150 - 440 103/µL
6
MPV 6.31 11.47 6.80-10.00 fl
CLINICAL CHEMISTRY
Parameter 07/2/2019 14/2/2019 Reference
Glucose 110 70-140 mg/dL
BUN 66 76.50 8.00-23.00 mg/dL
Creatinine 5.66 3.86 0.70-1.20 mg/dL
Uric Acid 8.1 2.00 – 7.00 mg/dL
AST 32 11.00-34.00 U/L
ALT 32.60 11.00-34.00 U/L
Albumin 2.30 3.12 3.50-4.80 g/dL
LDH 370 240 – 480 U/L

7
ELECTROLYTE

Parameter 07/2/2019 14/2/2019 Reference

Potassium 3.94 5.17 3.50-5.10 mg/dl

Sodium 125 124 136-145 mmol/L

Chloride 79 96 96 – 108 mmol/L

Calsium 6.8 8.4-9.70 mg/dL

8
 HEMOSTASIS
Parameter 08/02/2019 Reference

PT 13 10.8 – 14.4 detik

INR 1.04 0.9 – 1.1
APTT 29.4 24 – 36 detik

IMUNOLOGY
Parameter 08/02/2019 Reference

HBsAg NR NR: <0.90, Borderline:0.90-1, R: >1

Anti HCV NR NR: <0.90, Borderline:0.90-1, R: >1

9
BLOOD GAS

Parameter 07/2/2019 14/2/2019 Reference

pH 7.45 7.47 7.35-7.45
pCO2 24.6 20.5 35.00-45.00
pO2 102.60 159.60 80.00-100.00
BE -7.2 -9.0 -2-2
HCO3- 16.80 14.70 22.00-26.00
SO2 98 99.2 95% - 100%
TCO2 17.50 15.30 24.00 – 30.00

Respiratory alkalosis with metabolic acidosis compensation

Winter’s formula: 28-32  additional respiratory alkalosis
Anion gap: Normal
10
 PERIPHERAL BLOOD SMEAR (8/2/2019)

RBC Normochromic normositer, anisopoikilocytosis

(tear drops cells +, eliptocyte +)

WBC Normal in number and diff. count, toxic granule

(-), vacuolization (-), blast cell (-)
Platelet Decreased , giant platelet (-), clumping (-)

Image Normochromic normositer anemia with

thrombocytopenia

Suggestion - 11
 BONE MARROW SMEAR (15/2/2019)

Cellularity Hipocellular
Erythroid System Decreased activity

Myeloid System Decreased activity

Megakaryopoiesis Decreased activity
Other cell Plasma cells 20%, myeloma cell (+)

Conclusion Plasmacytosis support Multiple Myeloma

Suggestion Serum Protein Electrophoresis

12
Hipocellular Rouleaux Formation

13
Plasma Cell

14
Myeloma Cell

15
BIOPSY

16
DIAGNOSIS
1. LBP ec. MM st IIIB
2. CKD st. V ec mieloma kidney
3. Thrombocytopenia
4. Hipoalbuminemia

17
THERAPHY
1. O2 2 lpm
2. IVFD Nacl 0.9%
3. Albumin 5 g/100 ml
4. Folic Acid 2 mg (@12 hours)
5. Paracetamol 500mg (@6 jam)

18
 PROBLEM LIST
Pancytopenia
Azotemia
Hipoalbuminemia
Electrolyte
Respiratory alkalosis with metabolic acidosis compensation

19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42