Q122) A 75 year old man presents to your office with complaints of severe fatigue and constipation for the past one week. He has no significant past medical history except for benign prostatic hypertrophy for which he takes terazosin. Physical examination reveals mild tenderness in left mid thigh area. Rest of the exam is normal. An x-ray of the left lower extremity reveals a lytic lesion in the shaft of the femur. A subsequent bone scan reveals multiple lytic lesions in the ribs, right iliac bone, left and right femur shaft as well as in the left femur neck. The most important next step in managing this patient’s symptoms is :
A) Serum PSA level
B) Serum protein electrophoresis
C) Start IV Bisphosphonates
D) Check serum calcium level and start IV hydration
E) Skeletal surevey
Q123) The patient was admitted to the hospital and his symptoms were managed appropriately. However, during the second hospital day the patient complains of pain in his left thigh. Review of his previous x-ray reveals lytic lesion occupying the head and neck of femur. The most important immediate next step in managing this condition
A) MRI of the Hip
B) CT scan of the Hip
C) Orthopedic consultation for internal fixation
D) Radiation therapy
E) Chemotherapy
Archer USMLE Step 3 Blog 
B E
B,e multiple myeloma produces lytic lesions
D. It’s MM for sure but patient is presenting with hypercalcemia (constipation). So better to check Ca and start iv mean while his electrophoresis report can come back. Electrophoresis will not help manage hypercalcemia.
E. treat with chemo
ddd eee
anwer D E
Doing an electrophoresis now does not change the course of management . the vignette clearly tells us it’s a MM patient . Electrohporesis takes time and money . Hypercalcemia can cause severe symptoms such as confusion , altered mental status . Clue to that : Fatigues , constipation . thus we have to address this issue first .
If the question were to said : What’s the best next step to confirm this patient’s condition : that would be Serum electrophoresis
however question states what’s the next step in managing this patient’s SYMPTOMS .
Orthopedic consultatation is the next answer because patient complaints THIGH PAIN + LYTIC LESION OF FEMUR HEAD – possibility of femoral head osteonecrosis is high . We have to address this issue first .
Just my thoughts . feel free to comments. would love to know what other’s opinions are .
Very good analysis
i think there is no internal fixation for bone with lytic lesions
Why not MRI before ortho consult? Or are you letting the ortho surg order the MRI?
D and C. Management issues should be addressed first and not Multiple Myeloma. Giving chemotherapy or radiation will not treat his thigh pain that needs to be referred to the orthopedic surgeon. Hypercalcemia needs to be treated with IV hydration!
Very good! You are thinking very well!
On the topic of radiation vs internal fixation, here is a good article
http://www.bjj.boneandjoint.org.uk/content/94-B/11_Supple_A/22.full
D.
A.
D and A
I agree D and A, first manage the hypercalcaemia this patient has, patient clearly has MM as primary diagnosis. The patient has a lytic lesion of the neck of femur therefore risk of pathological fracture, to enable to determine the risk of fracture an MRI should be done first, low fracture risk can be treated with radiation, adn high risk intramedullary fixation. that applies to bony mets or primary tumor, not sure radiation works with MM, other wise orthopaedic consult