The next case is a 56 year old lady who was first referred to the hospital complaining of low back pain radiating to the left leg, and pain in her calves and thighs which was relieved by rest. She had also noticed that her legs had been more swollen than usual below the knees for the past four months, felt tired all the time and said her muscles felt tender. Investigations at this time showed a raised serum calcium (2.73mmol/l) and decreased serum albumin (28g/l).

The patient was found to have proteinuria. Urinalysis and electrophoresis showed a monoclonal IgG band - this is one of the characteristic findings in myeloma. Additional investigations showed a proteinuria of 11g/24hrs (ie a 24 hour urine sample contained 11g of protein), and decreased creatinine clearance (31ml/min).

Subsequently she was admitted to hospital with severe dyspnoea, orthopnea, oedema of the lower limbs, chest discomfort, cough, reduced urine output, and generalised aches and pains. On examination:

At this time, a diagnosis of nephrotic syndrome and congestive cardiac failure plus a possible pericardial effusion was made.

Chest XRay - confirmed right sided pleural effusion. Echocardiography - this showed moderate left ventricular hypertrophy with poor left ventricle function.

The patient then became acutely ill with hypotension (systolic BP 50mmHg). Her urea and electrolyte results taken at this time can be seen by clicking here.

The patient suffered a cardiac arrest shortly afterwards. She was resuscitated, transferred to ICU where she had another cardiac arrest from which she could not be resuscitated.