CRAB! I Have Bony Pain and a Fever – What Is Going On?

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CRAB! I Have Bony Pain and a Fever – What Is Going On?

August 12, 2023 | Family Medicine Exam Prep Course | CCFP

We are excited to see so many of you join our fall FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

Just a reminder… pay attention to the questions. Here are our general tips one more time:

1. Pay attention to the questions. Look carefully at how many items you are being asked to list. If the question asks for five items, you will not get more marks if you list eight items; the examiner will look at the first five and allocate marks only for the first five answers – so be careful. On a SAMP, if it is not clearly stated how many items you should list, look at the amount of points/marks being allocated for the question to get an idea of how many answers the examiner may be anticipating you write down.

2. Do not write lengthy answers. Most questions can be answered in 10 words or less!

3. Be specific when writing down investigations (hemoglobin instead of CBC; CT abdomen instead of CT).

4. Remember that trade names and generic names are both acceptable when writing down medications.

5. For more helpful tips, you can refer to CCFP’s SAMP instructions by clicking here.



67 year old Michael Jackson has returned to your clinic for the third time in the past month. He has been complaining of significant pain in his right shoulder and lower back. On several occasions in the evening, he has noted a fever and describes frequent chills. His past medical history is significant for Type 2 diabetes, Osteoarthritis, and Hypertension. His medications include Metformin, Perindopril, and Acetaminophen. He is a lifetime non-smoker. He lives with his wife and has a daughter who is involved in his care and has brought him today to your office. (11 points)

1. List four signs and/or symptoms that may be seen in Multiple Myeloma. (4 points)

    • Hypercalcemia (13% of cases)
    • Renal insufficiency (48% of cases)
    • Anemia (73% of cases)
    • Lytic bone lesions (67% of cases)
    • Neuropathy
    • Repeated infections
    • Unintentional weight loss
    • Bruising/bleeding

2. What investigations would you order to help diagnose Multiple Myeloma? List four. (4 points)

    • Hb
    • LDH
    • Serum calcium (corrected for albumin)
    • Serum-free light chain assay
    • Serum immunofixation electrophoresis
    • Serum protein electrophoresis
    • Creatinine/eGFR
    • ESR

3. True or false: Black/African American patients present at a younger mean age at diagnosis and so are more likely to get diagnoses with Multiple Myeloma. (1 point)

    • False. Black/African American patients have an increased prevalence of renal disease, diabetes, and mild liver disease that mimics symptoms associated with Multiple Myeloma. As a result, they are often misdiagnosed and the diagnosis of Multiple Myeloma is delayed.

4. Mr. Jackson’s bloodwork reveals serum calcium of 2.8, eGFR of 30, and hemoglobin of 90. Considering his shoulder and back pain, what imaging would you like to order? (1 point)

    • Skeletal survey
    • Low dose whole body CT

5. The imaging test you selected comes back as normal. Would you order any additional imaging if you are concerned about lytic lesions? (1 point)

    • Consider a PET-CT or MRI for bony pain
    • Note: This is typically reserved for ordering by the hematologist/oncologist

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