DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: Jane Doe, MD
CONSULTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Monoclonal gammopathy.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman with multiple medical problems who was admitted with generalized weakness. There is polydipsia and polyuria, in the setting of chronic pancreatitis. Other problems include renal insufficiency, atrial fibrillation, TIA, long-term congestive heart failure and history of anxiety disorder. During workup here in the hospital, she was found to have mild hypercalcemia and a serum immunofixation showed a kappa monoclonal gammopathy. We are consulted regarding the possibility of multiple myeloma. Her recent history is positive for acute renal failure. This was associated with pancreatitis-related diarrhea. She developed acute renal failure, which responded to IV fluids but she had some mild degree of chronic renal insufficiency since then. She has had significant anemia and had been treated by her renal doctor with Aranesp as an outpatient. Other medical history is positive for pacemaker placement for cardiac dysrhythmia. She has had previous cholecystectomy, cervical fusion and previous hand surgery.
MEDICATIONS ON ADMISSION: Coreg, Coumadin, coenzyme Q, Viokase, TriCor, Centrum Silver, magnesium and calcium.
ALLERGIES: MULTIPLE MEDICATION ALLERGIES.
FAMILY HISTORY: Negative for any bleeding or clotting disorders.
SOCIAL HISTORY: Nonsmoker and nondrinker.
REVIEW OF SYSTEMS: Review of 16 systems at this time is positive for general fatigue. She has got some joint aches. She has had some abdominal pain and bloating that she relates to her chronic pancreatitis. She is currently having no fevers or chills. No shortness of breath. No headache or focal weakness. She denies long bone pain or skull pain. She has had no difficulty swallowing. No hematochezia. She has had heme positive stool.
PHYSICAL EXAMINATION: On examination today, the patient appears somewhat younger than her stated age. Skin exam shows no petechiae, ecchymosis or jaundice. Thorough examination of lymph node bearing regions shows no cervical, supraclavicular, axillary adenopathy. HEENT exam shows no oropharyngeal lesions. No thrush. Neck is supple without masses or thyromegaly. Her lungs are currently clear bilaterally. Cardiovascular exam reveals a regular rate and rhythm without murmur, gallop or rub. Abdomen is soft, mildly distended, nontender throughout. Positive bowel sounds are present, although they appear hypoactive. Extremities reveal no clubbing, cyanosis or edema. She has good muscle strength throughout all four extremities.
LABORATORY DATA: Currently shows resolved anemia with a hemoglobin of 13.1, white count 5.8, and platelets 222,000. Her INR reflects her Coumadin use. Her creatinine is 4.7, total calcium is now normalized but on admission was 11.1. Total proteins were normal, globulin was normal. Thyroid function test were normal. Her intact PTH is in the normal range. Immunofixation showed monoclonal free light chain of kappa type hiding in the beta globulin zone.
IMPRESSION: Kappa monoclonal spike in this patient with renal failure and hypercalcemia. Multiple myeloma is a consideration. My suspicion is that she has a monoclonal gammopathy of unknown significance. Her hypercalcemia is probably related to underlying pancreatitis and the like. Nevertheless, multiple myeloma should be ruled out in this woman. She had a bone scan, which was negative, but this will not predictably pick up myeloma.
RECOMMENDATION: Bone marrow biopsy and aspirate, quantitative immunoglobulin levels and skeletal survey if bone marrow is positive. I have discussed this in detail with the patient. She is willing to proceed with bone marrow biopsy and aspirate. This has been ordered. We will await further recommendations pending those results.
