61 Y/M with multiple myeloma

61-year-old male, a mason by occupation presented to the casualty with 

complaints of fever for 10 days 

cough since 1week 

shortness of breath since 1week 

 HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 3 years back then he developed Involuntary movements of the right upper limb which was initially less intense then slowly progressed to the rest with an increase in amplitude and frequency, 

not associated with other abnormalities like weakness of limbs, giddiness, syncope.

 associated with slowing of movements and difficulty in turning while walking for the past 2years for which he even stopped working.

the patient went to a local practitioner for the same and was given medications but was in vain, he even traveled all the way to Karnataka to get his condition treated with local medication but was found to have no improvement in his symptoms

. 2 years back patient started to increase his alcohol consumption after his wife demise and was having these mood disturbances since then. 

10 days back patient developed

 Fever- 

high grade intermittent,

 no diurnal variation

 releived on taking medications 

not associated with chills and rigors,vomitings, loose stools,burning micturition. 

 Cough- initially dry cough later developed productive cough ,

 cough increased during early morning

 sputum - scanty, mucoid in consistency, white

 not associated with hemoptysis, post tussive vomiting 

 Shortness of Breath- insidious in onset,lasts for few seconds initially grade 2 later progressed to grade 3 releived on taking rest exertional dyspnea+ no orthopnea, PND, platypnea no diurnal variation not associated with chest pain, palpitations, syncope PAST HISTORY: patient had no similar complaints in the past not a known case of DM/HTN/ASTHMA/CAD/TB/EPILEPSY PERSONAL HISTORY: Farmer and mason by occupation stopped working 3 years back due to his weakness ROUTINE- wakes up at 5 am breakfast (idly, dosa) at around 9am then goes for a walk while chatting with his neighbours has his lunch at around 2pm (mostly rice, curry, dal) takes a nap for an hour , evening goes for a walk and has chat with his friends night dinner at around 8pm and then sleeps at 9 to 10 pm diet -mixed appetite - normal (decreased last 5 days) bowel and bladder regular sleep adequate addiction- occasional alcoholic since 20 years stopped 5 years back restarted after 2years tobacco (beedi 1 pack/day) FAMILY HISTORY: no relevant family history no similar complaints in his family IMMUNIZATION HISTORY: patient is not regularly vaccinated with annual flu shots PROVISIONAL : Lower respiratory tract infection with ?parkinsons disease GENERAL EXAMINATION 61 year old male sitting comfortably on bed patient is conscious ,coherent, cooperative well oriented to place and person not to time moderately built, poorly nourished PALLOR Present++ ICTERUS Absent CLUBBING Absent CYANOSIS Absent LYMPHADENOAPTHY present+ @upper jugular, middle, and lower jugular right side EDEMA mild pitting grade 1 VITALS: temperature-99F BP-110/70 mm of Hg bilateral arms supine position Pulse-92 bpm,regular in rate,rythm,normal in volume,consistency. bilaterally equal,no radiofemoral delay peripheral pulses felt RR-22 CPM, abdominothoracic type Saturations:97 on room air Skin- normal thyroid- no visible goitre nails -normal no koilonykia JVP- raised SYSTEMIC EXAMINATION RESPIRATORY- INSPECTION- shape -Ellipsoid breathing pattern-Abdomino thoracic,no retractions,No usage of accessory muscles drooping of shoulder present on right side supraclavicular fullness seen on right side, hollowing seen on left side no scars, sinuses, pulsations seen PALPATION- inspectory findings are confirmed no tenderness Anthropometry- total circumference- 45cm right left hemi thorax 22cm 23cm expansion on deep inspiration- 2cm asymmetrical, decreased on rt side mediastinum - shifted to right Vocal fremitus- Right Left MCL AAL MAL MCL AAL MAL Supraclavicular N N N N N N Infraclavicular N N N N N N Mammary inc inc inc inc inc N Inframammary inc inc inc inc inc inc Suprascapular equal equal Interscapular increased Infrascapular increased increased no palpable pleural rub no palpable thrills PERCUSSION- MCL AAL MAL MCL AAL MAL Supraclavicular R R R R R R Infraclavicular D D R R R R Mammary D D D D R R Inframammary D D R cardiac dullness R Suprascapular R R Interscapular R R Infrascapular D D *R - Resonant *D - Dull liver dullness @ 4th ics liver span - 14cm AUSCULTATION- Normal vesicular breath sounds heard bronchial sounds + @ mammary and infra mammary areas crepts head over right and left midaxillary at inframammary and mammary area aegophony + whispering pectorilquy + NERVOUS SYSTEM EXAMINATION Patient is conscious , coherent, cooperative oriented to place and person speech - normal memory- recent slightly decreased , remote intact (forgetfulness+) MMSE:20/ Cranial nerve- 1 - intact 2 - intact 3,4,6-intact , all movements eyes + 5- sensory, motor + reflexes+ 7- sensory, motor, secreatory , reflexes intact 8- intact 9,10,11- intact 12 -intact Motor system: bulk - inspection - normal palpation- normal Tone: right left upperlimb hypertonia hypertonia cogwheel rigidity lower limb normal normal Power: upperlimb 5/5 5/5 lower limb 5/5 5/5 Reflexes: Superficial- 1. Corneal + 2. Conjunctival + 3. Pharyngeal Reflex + 4. Palatal Reflex + 5. Abdominal Reflex + 6. Cremasteric Reflex + Deep tendon reflexes- Biceps +++ +++ Triceps ++ ++ Supinator ++ ++ Knee ++ ++ Ankle ++ ++ Plantar flexors flexors Gait: short shuffling gait+ difficulty in turning around Involuntary movements: tremors+ Sensory: all sensations are intact Cerebellar signs: titubation absent dysdiadokokinesia absent truncal ataxia absent nystagmus absent Autonomic nervous system: intact No signs of meningeal irritation carotid pulses normal and bruit absent GASTROINTESTINAL SYSTEM Inspection - scaphoid , no scars , sinuses , visible peristalisis Palpation - non tender hepatomegaly + firm consistency,liver span (13 cm) spleenomegaly present , 3 fingers insunating below ribs, notch felt, non tender percussion- tympanitic note auscultation- normal bowel sounds heard CARDIOVASCULAR SYSTEM Inspection- no visible pulsations, normal shape Palpation: no palpable heart sounds apex beat at 5th ICS at MCL Percussion- heart borders with in normal limits Auscultation- S1 and S2 heard , no additional murmers or heart sounds heard INVESTIGATIONS: 

 PROVISIONAL DIAGNOSIS:

[05/09, 23:02] Dr.Deepika Ch: Today's new admission

AMC bedno 5

61 year old male with complaints of shortness of breath since 3 days

Dry cough since 3 days

History of fever 1week back

Involuntary movements of Rt upper limb since 3 years

HB. 4.6 gm/dl

TLC 44,100

PLATELETS. 40,000

Provisional diagnosis: 

Community acquired pneumonia with bicytopenia

[05/09, 23:40] Dr Raveen Pg Gmed 2: A 61 year old male used to work as a mason, non diabetic, non hypertensive presented to casualty with history of fever, dry cough since 10-15 days, Involuntary movements of right upper limb since 3 yrs, Worsening of Shortness of breath since 10-15 days 

He was his usual self 3 years back, noticed involuntary movements of right upper limb while being at rest and subsided on movement, 

Since 2yrs after the demise of his wife, he was unable to bear the loss, he kept much of himself private and indulged in alcohol and smoking ( 1 pack per day 18beedis) and has reformed since one year, he also noticed awareness of his heart beat lasting for 15-20 mins occasionally and shortness of breath, class 1-2, denied for pedal oedema, orthopnoea and PND.

He also mentioned he has observed slowing of movement and ??decrease in pitch of his voice since 1-2 yrs and stopped going to work, rather occasionally ( he even built his daughters house 1 yr back ), he was prescribed medications ( December 2021 ) for his involuntary movements which resulted in vain after using for 5 months 

In April 2022, after his second sons marriage he apparently slept in an abnormal posture with his elbow flexed and waking up next day he wasn’t able to lift his left upper limb over the head and has been that way till now 

2 months back he went to Karnataka for his involuntary movements being said herbal medication is the remedy, on not subsiding stopped using after 2 weeks

Since 10-15 days, he developed fever, high grade intermittent type lasting for 3-4 days with chills, developed cough without expectoration and shortness of breath grade 1-2 ( walking for upto 500m) previously he used to go on bicycle in between the villages.

He has 2 sons and 2 daughters 

He stays with his elder son and his wife and occasionally younger son comes and stays with them as he works in Hyderabad 

He owns three acres of land looked after by his elder son and is growing cotton 

While taking history he identified his elder daughter for younger daughter, on asking his grand son he’s often forgetting things and lethargy. 

General examination 

Pallor ++

JVP raised 

Cylindrical chest 

Right parasternal pulsation 

No palpable P2 

Apex beat localised to 5th ICS 

RS - b/L early inspiratory crepts in b/l subclavicular area, mammary areas 

and right infra Axillary areas 

Egophony+ 

CNS 

Right handed 

Oriented to time place person 

Able to recall events with delay in response 

Speech normal 

No cranial nerve deficits 

No loss of power 

Tone increased on right Upper limb 

??Cog wheel 

Hyper reflexia of biceps, triceps, supinator 

2+ for knee 

Absent ankle b/l

B/L Plantars withdrawal +

Mild pitting oedema ( ??upto ankle )

[06/09, 07:37] Dr Rakesh Biswas Sir HOD: When was his wife's demise? Your entire timeline depends on this missing information?

[06/09, 07:40] Dr Raveen Pg Gmed 2: 2 years back sir 

2020 august

[06/09, 07:42] Dr Rakesh Biswas Sir HOD: That fits into early Parkinsonism

[06/09, 07:44] Dr Rakesh Biswas Sir HOD: @⁨Dr Ashiness kashyap Mam⁩ Can you share which of the recent cases that you published was quite similar to this one?

[06/09, 07:52] Dr Raveen Pg Gmed 2: One more thing is sir 

Abdomen is showing 

Hepatomegaly and splenomegaly too 

His old reports were showing 

Hb of 10.9 in December 

Yesterday’s was showing 4.6

[06/09, 07:52] Dr Rakesh Biswas Sir HOD: How many fingers below the costal margin?

[06/09, 07:55] Dr Raveen Pg Gmed 2: Spleen 3 fingers sir 

Below the left costal margin 

Liver after insinuating 

Probably one finger below the coastal margin

[06/09, 07:55] Dr Rakesh Biswas Sir HOD: Chronic anemia and sepsis precipitating acute LVF other than his background problem of Parkinsonism

[06/09, 07:56] Dr Rakesh Biswas Sir HOD: Acute malaria or other undifferentiated sepsis causing organisms such as Salmonella? 

Consistency of the spleen?

[06/09, 07:56] Dr Rakesh Biswas Sir HOD: Hope we sent his blood cultures before treating his antibiotic deficiency?

[06/09, 09:11] Dr Ashiness kashyap Mam: Very well presented @⁨Dr Raveen Pg Gmed 2⁩ ☺️

Have you checked his MMSE? 

Any autonomic symptoms ? Have you checked for orthostatic hypotension ?

[07/09, 13:13] Dr.Deepika Ch: The diagnosis of CLL requires the presence of more than or equal to 5 × 109/L B lymphocytes (5000/μL) in the peripheral blood for the duration of at least 3 months. The clonality of the circulating B lymphocytes needs to be confirmed by flow cytometry. The leukemia cells found in the blood smear are characteristically small, mature lymphocytes with a narrow border of cytoplasm and a dense nucleus lacking discernible nucleoli and having partially aggregated chromatin. These cells may be found admixed with larger or atypical cells, cleaved cells, or prolymphocytes, which may comprise up to 55% of the blood lymphocytes.5 Finding prolymphocytes in excess of this percentage would favor a diagnosis of prolymphocytic leukemia (B-cell PLL). Gumprecht nuclear shadows, or smudge cells, found as cell debris, are other characteristic morphologic features found in CLL.

[07/09, 13:14] Dr.Deepika Ch: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2972576/