CASE 1:

One week after the executive check-up, patient went to the ER due to abdominal pain. He said that the
vague pain started periumbilically the night before ER consult, then shifted to the RLQ the morning before
going to the ER. He also experienced loss of appetite, nausea and vomiting.

On physical examination, the patient showed abdomen guarding at the RLQ with direct and rebound
tenderness, (+) Rovsing sign, (–) psoas sign, (+) obturator sign. Incidentally, you noticed upon careful
examination that the patient develops a bulge at the umbilical area that reduced upon lying down. On
palpation, there is a 2 x 1.5 cm hole at the umbilical area

1. Biochemically describe how insulin is released following an oral glucose load and how it
normalizes blood sugar levels in the fed state. What are the proposed mechanisms behind
development of diabetes mellitus? Is high sugar consumption directly related to its development?
2. Why do you think LDL-C and triglycerides are elevated in this patient? Are there risk factors
present in the patient that predisposes him to dyslipidemia?
3. How will the patient’s condition/s affect the hepatic and skeletal metabolism of amino acids? What
is the overall effect on the patient (other organs/systems)? Focus on relating the fate of amino
acids to the other possibly deranged metabolic pathways.
CASE 2:

This is a case of a 50 year old female nurse who was brought to the DLSUMC emergency room
by her relatives because of severe persistent upper back and rib cage pain that started 4 weeks
prior to admission. 2 weeks prior to admission the patient developed left and right lower
extremity weakness and numbness, with associated increasing pain severity on her upper back.
Other symptoms include inability to move her right hand and arm with developing numbness
and weakness on her left arm.. 3 days prior to admission, the patient developed a productive
cough with yellowish phlegm with associated pleuritic chest pain.. Other associated symptoms
upon admission include severe body weakness, lack of energy, loss of appetite, headache,
nausea and vomiting and inability to void for the past 24 hours. Progression of pain severity and
weakness prompted the patient’s relatives to seek medical help at DLSUMC.

The patient’s personal and social history were unremarkable.

The patient’s past medical history revealed that she was diagnosed to be suffering from chronic
cholecystitis during the time that she was working abroad as a hospital nurse in Qatar. The
patient worked in a hospital in Qatar for the past 15 years and was frequently treated in their
hospital because of recurrent abdominal pain due to chronic cholecystitis.She was also
frequently treated for recurrent back pain in the hospital that she was working in 2 years before
she retired from her hospital work in Qatar. She frequently undergoes physical therapy
treatment in their physical rehabilitation department due to her recurrent upper back pain. After
undergoing a complete laboratory and radiographic work up including CT scan of her back
because of persistent back pain 2 months before retiring from her overseas hospital work ,the
patient eventually underwent surgery in her back where a small 2cm, reddish colored soft,
gelatinous mass in her thoracic vertebrae was surgically removed in the same hospital that she
was working in approximately 1 year prior to admission. Histopathologic studies done in the
hospital laboratory where she was working apparently showed that the resected tumor is an
osseous type of solitary myeloma or plasmacytoma according to their Chief Pathologist.

After her surgery, she was advised by her attending physician to retire from her hospital work
and go home to the Philippines to recuperate and seek further medical treatment should there
be a recurrence of her tumor.

At the DLSUMC ER, physical examination was done by her attending physician and the
following findings were noted:

General Survey: The patient is conscious, incoherent, disoriented to time,place and person,very
weak, cachectic, in pain and in cardiorespiratory distress

1) Vital signs:
- BP = 150/90mm Hg (Normal value-Equal or less than 120/80mm/Hg) - PR = 120 beats
/min (Normal value-60-100 beats/min)
- RR = 30 cycles/min (Normal value-12-16 cycles/min)
-Temperature= 35.5 degrees centigrade

2) Head and neck, eyes, ears nose and throat-Pale palpebral conjunctivae
- Patient was noted to have blurred vision and diplopia
 - Funduscopic examination done showed congestion and pronounced tortuosity of retinal
veins and retinal hemorrhages.
-Alar flaring was noted

3) CVS - + Tachycardia

4) Chest and Lungs - Breath sound is absent on the patient’s right lung, vesicular breath sound
was noted on the left lung.
-ICS retraction was observed

5) Abdomen - Hyperactive bowel sound of 40/minute (Normal value - 5 - 30/minute)

Based on her medical history and physical examination done upon admission in DLSUMC, her
attending physician ordered the following laboratory workup:

1) Chest x ray PA view showed lobar consolidation involving her right lung suggestive of
pneumonia.
2) Skull xray showed multiple, focal, sharply punched out lesions in the skull.

3) X ray AP lateral view of both right and left femur showed the same multiple punched out
lesions with associated cortical bone defects suggestive of pathologic fractures.

4) X ray AP Lateral view of the thoracic, lumbar and sacral vertebrae also showed the same
multiple punched out lesions with cortical defects or erosions.
- These multiple,focal,sharply punched out bone lesions are highly suggestive of a type
of plasma cell dyscrasia known as Multiple Myeloma.
- The cortical defects or erosions are suggestive of multiple pathologic fractures affecting
the patient’s vertebrae,ribs,and both femoral bones.

5) Blood serum calcium level of the patient is 12.5mg/dl (Normal Value=8 - 10mg/dl).
6) ESR (Erythrocyte Sedimentation Rate) - 49mm/hr. (Normal Value is 0-29 in female and for
male-0-22mm/hr).

7) Serum creatinine - 10mg/dl (Normal Value-.8-1.2mg/dl).

8) Complete Blood Count-Hemoglobin = 9g/dl (Normal Value = 12 to 15g/dl in female/14 to

17g/dl in male).
- Hematocrit is 25% (Normal Value in female-36-48%,In male-40-54%).
- WBC count = 1,500/microliter (Normal Value-5,000-10,000/microliter).
- Platelet count = 50,000/microliter (Normal value is 150,000 to 450,000/microliter).

9) Peripheral smear shows RBC which is normocytic and normochromic but reduced in
number.
- With leukopenia and thrombocytopenia. Rouleaux formation in some RBCs were
also noted.

These radiologic and blood serum laboratory results prompted the patient’s attending physician
to order additional examinations and the results are as follows:

1) Blood electrophoretic analysis test (Serum Protein Electrophoresis) done on the patient’s
blood showed abnormal substances called M proteins or Myeloma proteins which is composed
of Ig G and Ig A (Heavy chain protein component).

2) Urine Electrophoresis (Urine Protein Electrophoresis) meanwhile showed presence of Bence

Jones proteins (These abnormal protein light chains are composed of Kappa and Lambda light
chain protein components).

3) Bone marrow aspiration biopsy was also done on the patient showing masses of mostly
mature plasma cells but some with anaplasia and forming tumor giant cells.

4) Kidney biopsy revealed presence of proteinaceous casts(Composed of

albumin,immunoglobulins as well as Kappa and lambda light chains corresponding to your
Bence Jones proteins)surrounded by multinucleated giant cells inside the distal convoluted
tubules and collecting tubules.
Course in the ward:
- The patient was eventually admitted to the ICU and was intubated and put on a
respirator.
- Indwelling foley catheter was inserted but no urine output was observed in the past 24
hours.
- Antibiotic was given (Ceftriaxone 1 gram/24 hrs) but the patient expired on the 2nd day
of her stay in the hospital.

1. What are monoclonal proteins and what is its significance?

2. How does the ongoing infection in the patient worsen the anemia?
3. Explain the basis behind the noted Rouleaux formation among the patient’s RBCs.