A challenge

Discussion in 'Internal Medicine and IM Subspecialties' started by Gokhu, May 8, 2007.

  1. Gokhu

    Gokhu Membership Revoked
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    A 72 yp pt has Alk. phos 300 and Calcium 7 mg/dL, LDH 530. Otherwise his labs are normal.
    What do you suspect?
     
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  3. GooglieGoo

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    That you're a second year student who doesn't want to look up the answer to a test question yourself.
     
  4. vkrn

    vkrn Senior Member
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    Note OP's join date, but appreciate OP's M.I.N.D. effort.
     
  5. GooglieGoo

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    "M.I.N.D. effort"? Google is failing me.
     
  6. Geri_Gal

    Geri_Gal Loving Life
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    I thought the OP was trying to engage in clinical discussion. Posters in the anesthesiology forums often do this -- it is quite interesting to read. I'll bite...any more history? My brain is on "vacation" mode until June 12th!

    ...and what is "M.I.N.D." effort?
     
  7. Adcadet

    Adcadet Long way from Gate 27
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    Some history would be nice! Maybe a gender, too! I'm assuming that this patient is roughly normotensive (helps eliminate weird adrenal problems, including Addison's and pheo), and the Cr and BUN were normal as well. I love checking TSH's, and assume this patient's TSH is normal or he/she is on appropriate replacement.

    I don't know what your lab's normals are, but it would seem the alk phos, Ca, and LDH are all up. This suggests a process that is destructive of bone and some cells are dying (LDH is up), and I would love some history - any bone pain? My immediate suspicion would be towards multiple myeloma, especially given the patient's age, and I would get an SPEP/UPEP to look for a monoclonal spike. Paget's might also do this (hmm...will Pagets give you an elevated LDH?) TB could also do some of this (do we exposure history, or maybe a PPD?), as could other malignancies (add in a uric acid as we want to watch for tumor lysis syndrome and it would be nice to have a baseline). If there are any localizing complaints I would go for some plain films. Do we have an ESR or CRP? If it's looking like Pagets or MM I might start thinking about a bone scan.

    OK, did this soon-to-be intern miss something major?
     
  8. vkrn

    vkrn Senior Member
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    MIND is the free software that the OP has offered to folks. I haven't tried it so can't vouch for anything.
     
  9. stergs

    stergs New Member

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    Ca of 7 is low; depending on the Albumin. Find the proper ranges first.
     
  10. Adcadet

    Adcadet Long way from Gate 27
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    Sort of defeats the purpose if I look everything up.
     
  11. lfcdoc

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    I dont' know if you've missed something as I too am only a soon to be intern. (yikes) For me though, I thought mutiple myeloma only increases your alk phos if you also have a fracture, and also I would expect high Ca instead not low. I don't know if Paget's can give you an inc. LDH, but I think it usually has a normal Ca (isolated increased alk phos is the textbook picture I think, but yes, I know the patient's didn't read the book).

    I agree the bone mets/mlgncy is a good thought. I think that a blastic lesion could increase the alk phos (bone turnover) and lower the calcium (b/c it's blastic). So are there any malignancies that would have blastic mets and an increased LDH as a marker? I'm not sure, would have to took it up and I'm too lazy right now.
     
  12. iatrosB

    iatrosB trying not to kill anyone
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    possibly prostate cancer (patient gender?)

    I think you're right about the MM not raising Alk phos
     
  13. Gokhu

    Gokhu Membership Revoked
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    -------------------------------
    Snap differential
    -------------------------------
    1. Hypocalcemia: - MEASURE SERUM MG, , , , , Detected, MIND score: 6
    2. Pancreatitis - High LDH, Low serum total calcium, MIND score: 2
    3. Sepsis: - High Alk.Phos, Low serum total calcium, MIND score: 2
    4. Liver failure: - Hilg Alk.Phos., , MIND score: 2
    5. Liver tumor: - High LDH High Alk.Phos. MIND score: 2
    6. Epstein Barr virus: - High LDH High Alk.Phos. MIND score: 2
    7. Cytomegalovirus: - High LDH High Alk.Phos. MIND score: 2
    8. Pulmonary infarction: - High LDH High Alk.Phos. MIND score: 2


    9. Myocardial infarction: - High LDH, MIND score: 1
    10. Vit D def. - Low serum total calcium, MIND score: 1
    11. Pseudohypoparathyroidism - Low serum total calcium, MIND score: 1
    12. Hypomagnesemia: - Low serum total calcium, MIND score: 1
    13. CNS lesion: - High LDH, MIND score: 1
    14. CHF: - High Alk.Phos, MIND score: 1
    15. Hyperthyroidism: - High Alk.Phos, MIND score: 1
    16. Hyperparathyroidism: - High Alk.Phos, MIND score: 1
    17. Kidney Infarction: - High LDH,MIND score: 1
    18. Cerebrovascular accident: - High LDH,MIND score: 1
    19. Cardiopulmonary disease: - High LDH,MIND score: 1
    20. Ischemic hepatitis: - High LDH,MIND score: 1
    21. Liver metastasis: - High LDH,MIND score: 1
    22. Collagen Vascular Disease: - High LDH,MIND score: 1
    23. Megaloblastic anemia: - High LDH,MIND score: 1
    24. Intestinal Obstruction: - High LDH,MIND score: 1
    25. Muscle trauma: - High LDH,MIND score: 1
    26. Hypotension/Shock: - High LDH,MIND score: 1
    27. Neoplasm: - High LDH,MIND score: 1
    28. Vitamin B12 deficiency: - High LDH,MIND score: 1
    29. Folate deficiency: - High LDH,MIND score: 1
    30. Fluid sequestration: - Pancreatitis suspected x2, MIND score: 1
    31. Hypothyroidism: - High LDH, MIND score: 1
    32. Multiple myeloma :luck:- High Alk.Phos, MIND score: 1
    33. Paget's disease of bone - High Alk.Phos, MIND score: 1
    34. Vit. D toxicity - High Alk.Phos, MIND score: 1
    35. Acromegaly - High Alk.Phos, MIND score: 1
    36. Blood transfusion - High LDH, MIND score: 1
    37. SLE: - High LDH, MIND score: 1
    38. Hemolysis: - High LDH, MIND score: 1
    39. Leukemia. - High Alk.Phos, MIND score: 1
    40. Estrogen. - High Alk.Phos, MIND score: 1
    41. Ulcerative colitis: - High Alk.Phos. MIND score: 1
    42. Bowel Perforation: - High Alk.Phos. MIND score: 1
    43. Fatty liver: - High Alk.Phos. MIND score: 1
    44. Alcoholic Hepatitis: - High Alk.Phos. MIND score: 1
    45. Primary Biliary Cirrhosis: - High Alk.Phos. MIND score: 1
    46. Drug-induced liver disease: - High Alk.Phos. MIND score: 1
    47. Hepatic granuloma: - High Alk.Phos. MIND score: 1
    48. Hepatic cyst: - High Alk.Phos. MIND score: 1
    49. Cholecystitis: - High Alk.Phos. MIND score: 1
    50. Cholelithiasis: - High Alk.Phos. MIND score: 1
    51. Primary Sclerosing Cholangitis: - High Alk.Phos. MIND score: 1
    52. Oran contraceptives: - High Alk.Phos. MIND score: 1
    53. Albumin injected: - High Alk.Phos. MIND score: 1
    54. Myelofibrosis: - High Alk.Phos. MIND score: 1
    55. Erythromycin: - High Alk.Phos. MIND score: 1
    56. Phenothiazines: - High Alk.Phos. MIND score: 1

    www.floeos.com :luck:
     

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