1. MGR DEPARTMENT OF HEMATOONCOLOGY

2. 11741919 이 O 섭 (M/72) adm. 04-10-19 C. C) Back pain o/s) 2 months ago P.I) 72 세 남자, 2 개월 전부터 특별한 trauma history 없이 요추부 통증 지속되고, 2 개월간 4kg 체중감소 있어 개인병원 에서 3 차 병원 권유 받고 further evaluation 위하여 입원.

3. PMHx.) DM/HTN/pul.Tb/hepatitis (+/-/+/-) type 2 DM : 4 년전 진단 받고 경구혈당 강하제 복용 중 Pulmonary Tb: 10 년전 medication op. Hx :(-) Drug Hx : 경구혈당 강하제 (+) FHx.) unremarkable PHx.) alcohol (-) smoking (-)

4. Review of System General wt. loss(+) :4Kg/2M fatigue(+) fever(-) chills(-) Skin itching (-) sores (-) H/N headache(+) stiffness(-) sore throat(-) Resp. cough(-) sputum(-) dyspnea(-) Cardiac. chest pain(-) DOE(-) orthopnea(-) palpitation(-) HTN(-) G.I A/N/V/D/C(-/-/-/-/-) melena(-) hematochezia(-) abdominal pain(-) Urinary. hematuria(-) oliguria(-) nocturia(-) Endo. polydipsia(-) temperature tolerance(-) Nervous. syncope(-) seizure(-) dizziness(-) tremor(-) Musculoskeletal. backache(+) : L1 level, worsened by movement, absent at night, radiating pain(-) Extrimity paresthesia(-) & weakness(-)

5. Physical examination V/S 130/80 mmHg-96 회 /min-20 회 /min-36.2°C G/A not so- ill looking appearance alert consciousness Skin no rash no pigmentation intact skin tugor H/N normocephaly no thyroid gland enlargement no cervical, supraclavicular LNE no neck vein engorgement E/ENT isocoric pupil with PLR(++/++) pale conjunctiva not yellowish sclera PI (-/-), PTH (-/-)

6. Physical examination  Thorax clear breath sound without rale regular heart beat without murmur Abd. Soft & flat abdome normoactive BS no abdominal palpable mass no abdominal tenderness/RTd Back/ext no CVA tenderness no peripheral pitting edema Neurology: L1 spine tenderness Both leg sensory & motor abnormality(-/-) SLR test (-/-) knee & ankle DTR (++/++)

7. Impression 1. Tb spondylitis R/O Osteoporosis c Compression Fx R/O Bone metastasis R/O MM 2. type 2 DM

8. Diagnostic plan T, L-spine series, if needed spine MRI Chest PA CBC/DC, Chemistry, PBS U/A, urine chemistry Bone marrow exam Serum & urine PEP

9. Laboratory finding(04-10-19) CBC 4,170/mm 3 -7.8g/dL-24.3 %-195K (seg 44%) MCV: 104.5fLMCH: 33.9pgMCHC: 32.3g/L PBS : Normocytic, rouleaux formation (+) S-Fe : 80 (50-150)ug/dL TIBC: 177 ug/dL TSAT : 45(30-50)% s-ferritin : 153 (50-200)ug/L Reticulocyte count /corrected reti/ RPI 1.8 %/0.97%/0.49 ESR : 65 mm/hr CRP : <0.5

10. Laboratory finding(04-10-19) Chemistry TB/DB 0.4/0.1 mg/dl prot/alb 10.1/2.5 mg/dl AST/ALT 19/17 U/L ALP/  GT 38/6 U/L glucose 152 mg/dl LD 322 U/L Ca/P/Mg 8.5/3.2/2.1 mg/dL BUN/Cr 20/1.1mg/dl Na/K/Cl 134/4.0/113 mmol/L HbA1C : 8.5% UA) OB (-) prot. (-) SG 1.025 pH 5.5 RBC 0~1/HPF WBC 0~1 /HPF

11. Laboratory finding(04-10-21) Tumor Marker  CA19-9 :4  CEA : 1.79  AFP : 1.27 24hrs urine collection  Protein 207 mg/day, Cr 1120 mg/day  CrCl 70.7 ml/min, urine volume 2300ml

12. Chest PA

13. T L - Spine

14. L-Spine MRI

15. Initial Assessment Back Pain, Osteoporosis, L1 comp Fx Wt Loss Anemia Prot. 증가, reverse A/G ratio PBS : rouleaux formation (+)  Multiple myeloma 의심 Known Type 2 DM

16. Skull Series

17. Serum PEP (04-10-21) Suggestive Monoclonal gammopathy

18. SERUM IMMUNOFIXATION ELECTROPHORESIS abnormal zone of restriction in IgG and Kappa light chain monoclonal gammopathy IgG and kappa type

19. Laboratory finding(04-10-21) Ig G 7750 mg/dL Ig A 37 mg/dL Ig M <17 mg/dL Ig E 53 IU/mL Free light chain FLC (kappa/lamda) : 5.3 (0.67-1.38) FLC (kappa) : 70.5 mg/L FLC (lamda) : 13.3 mg/L

20. Laboratory finding(04-10-21) Bone marrow :  Biopsy: plasma cell 21.2%  Multiple myeloma  Karyotype: 46,XY,t(3:14)(p25;q32)[3]/46,XY[16] Multiple myeloma with a 14q+ B2-microglobulin : 4.2 (0-2.4)mg/L

21. BM Finding

23. Final Diagnosis Multiple myeloma IgG/ Kappa type

24. Plan Treatment Chemotherapy MP regimen F/U Lab data  Serum & urine PEP (M-prot peak) check  Serum Immunoglobulin  Serum B-2 microglobulin

25. Clinical course

26. 04-10-2104-12-2705-2-21 05-3-2205-4-27 5.4 3.32.5 1.7 1.5 M-Peak Change

27. Immunoglobulin

28. β2-Microglobulin

29. Laboratory finding(05-05-19) CBC : 3,630/mm 3 -11.5g/dl-34.0 %-159K (seg 64%) MCV: 99.7 fL MCH: 33.6pg MCHC: 33.7g/L prot/alb 6.9/3.0 mg/dl Ca/P/Mg 8.9/2.6/1.9 mg/dL BUN/Cr 17/0.9mg/dl 24hrs urine collection Protein 84 mg/day, CrCl 63.4 ml/min