A 60-year-old man presents with generalized bone pain and easy fatigability. X-rays show diffuse osteoporosis, and hypercalcemia is noted. Which of the following investigations is most appropriate to confirm the diagnosis?

1. A

   CT scan

2. B

   Bone marrow biopsy

3. C

   MRI

4. D

   Sestamibi scan

Appeared in: AIIMS Delhi NO-2016

Explanation

• The clinical scenario strongly points towards multiple myeloma, a cancer of plasma cells.
• A bone marrow biopsy is the definitive diagnostic test for multiple myeloma.
• The biopsy confirms the diagnosis by showing a clonal proliferation of plasma cells (usually >10%) in the bone marrow.
• This test provides a direct tissue diagnosis, which is essential for confirmation, unlike imaging studies.

Why Other Options Were Wrong

• Option A: A CT scan is an imaging study that can identify bone lesions characteristic of myeloma but cannot confirm the diagnosis at a cellular level.
• Option C: An MRI is highly sensitive for detecting bone marrow infiltration and is the best imaging modality for evaluating suspected spinal cord compression, a complication of myeloma. However, it does not provide a tissue diagnosis.
• Option D: A Sestamibi scan is used to diagnose primary hyperparathyroidism, another cause of hypercalcemia. It is not relevant for diagnosing multiple myeloma.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Diagnostic workup for Multiple Myeloma to guide bedside assessment, documentation, and the next nursing action.
• Nurses play a crucial role in preparing patients for a bone marrow biopsy. This includes ensuring informed consent, positioning the patient (typically in a prone or lateral decubitus position), providing sedation and local anesthesia, and offering emotional support.
• Post-procedure, the nurse must monitor the biopsy site for bleeding or hematoma, manage pain, and instruct the patient on site care.
• What if? If the patient's lab results showed hypercalcemia but a normal complete blood count and no bone pain, the initial investigation would more likely focus on hyperparathyroidism. In that case, checking a parathyroid hormone (PTH) level would be the first step, and a Sestamibi scan might follow if the PTH level was elevated.

How to Approach the Question

• First, analyze the clinical vignette to identify key signs and symptoms: 60-year-old male, bone pain, fatigue, osteoporosis, and hypercalcemia.
• Recognize that this combination of findings (especially hyperCalcemia, potential Renal issues, Anemia causing fatigue, and Bone lesions/pain) is classic for Multiple Myeloma (CRAB criteria).
• Consider the differential diagnosis. Hypercalcemia could also be from hyperparathyroidism, but the other symptoms make myeloma more likely.
• Evaluate the question's objective: to confirm the diagnosis. This implies the need for a definitive test, which is usually a tissue biopsy.
• Assess the options: CT and MRI are imaging tests that support the diagnosis but don't confirm it. Sestamibi scan is for a different diagnosis (hyperparathyroidism).
• Conclude that bone marrow biopsy is the only option that provides a definitive histological confirmation of the suspected disease.

Concept Tested & Keywords

• Concept Tested: Diagnostic workup for Multiple Myeloma
• Stem keywords: generalized bone pain, easy fatigability, diffuse osteoporosis, hypercalcemia, confirm the diagnosis
• Lead-in keywords: most appropriate
• Clinical cues: The combination of bone pain, fatigue (suggesting anemia), and hypercalcemia in an older adult is a classic triad for multiple myeloma (part of the CRAB criteria).

Question ID

QHrIiT0VRl1hi8bLLSgbG8

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 1 p. 930-932

E6 Medicine Harrison 22e Part 2 p. 1203-1205