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CT scan of head
1%
44/3570
Urine electrophoresis
43%
1526/3570
Lower extremity electromyelography
38/3570
Lumbar puncture
30/3570
Bone marrow aspiration and biopsy
54%
1914/3570
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The patient's clinical history, imaging, and lab values are indicative of multiple myeloma. The next most appropriate investigation for the diagnosis of multiple myeloma would be bone marrow aspiration and biopsy. A diagnosis of multiple myeloma may be based on the Durie and Salmon criteria. The criterion considers findings of plasmacytomas on tissue biopsy, plasmacytosis in bone marrow, monoclonal immunoglobulin spike on serum or urine electrophoresis, and radiographic evidence of lytic bone lesions (commonly in the spine, long bones and skull). Walker et al. looked at the effectiveness of MRI on the clinical diagnosis of multiple myeloma. They showed that MRI detected focal lesions in 74% of cases, compared to 56% with standard metastatic bone surveys (e.g. radiographs) of imaged anatomic sites. Palumbo et al. reviewed multiple myeloma. They state that bony lesions are evident on MRI in 80% of patients with newly diagnosed disease. Anemia, which is present in about 73% of patients at diagnosis, is related to bone marrow infiltration and/or renal dysfunction. Figures A shows T2 MRI images of the thoracic and lumbar spine with diffuse lucencies throughout. Illustration A and B demonstrate a sheet of round plasma cells consistent with the histology of multiple myeloma. There is an eccentric nucleus, prominent nucleolus, and clock-face organization of chromatin. Illustration C shows the most common sites of multiple myeloma in the body. Incorrect Answers: Answer 1: A CT head is not necessary. Bony lesions in the skull can typically be detected on radiographs. Answer 2: Urine electrophoresis would not be needed as there was presence of a serum monoclonal protein. Answer 3: Electromyelography technique is used to evaluate the electrical activity produced by skeletal muscles, which can help diagnose peripheral nerve damage. This would not be used for the diagnostic work-up of multiple myeloma, however it may be used as adjunctive test for the investigation of his left leg sciatica. Answer 4: There is no evidence to suggest lumbar puncture is indicated for the diagnosis of multiple myeloma.
2.5
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