Table 1 Relevant past medical history and interventions

Day 1

Patient’s primary concerns were 3 days of diarrhea and generalized abdominal pain

• Abdominal X-rays: generalized colon distension without obstruction signs

• Chest X-rays: pleural fluid in the left basal lung

• Chest CT scan: atelectasis in the left basal lung

• Neutrophilia

• Decreased albumin/globulin ratio

• Normal electrolytes

• Normal serum osmolality

• Normal stool test

In the emergency room:

• endogenous fluids

• antibiotics

• albumin

Day 2

We found a right lower quadrant mass on abdominal palpation.

Patient showed significant clinical improvement

• Abdominal CT with contrast: sigmoid diverticulosis and a 4.96 cm diameter right iliac crest mass

• Biopsy of the mass: plasmacytoma

• Thorax CT: severe lytic lesions

• Skeletal survey: multiple lytic lesions in the skull, femur, and humeral head

• Hyperproteinuria

• Alpha-2 monoclonal peak

• He was tolerating oral daily diet

• Diarrhea stopped

• Physical therapy

• Pulmonary-respiratory therapy with vibration and positive pressure exercises

Day 5

Clinically stable

• Urine immunofixation came back positive for monoclonal gammopathy component type Kappa IgG

• Bone marrow biopsy: high expression of CD38 and CD56, compatible with a plasmatic cell neoplasia

• Multiple myeloma was confirmed

• Bortezomib was started

Day 12

Acute productive cough of white sputum

• Thorax X-rays: pulmonary edema plus new costal fractures

• BNP was elevated to 307 pg/ml

• Hb was decreased to 10 mg/dl

• Transferred to intensive care unit

• Furosemide

• Erythropoietin

• Transfused with pack red blood cells

Day 17

Mental status progressively deteriorated.

Cardiorespiratory arrest

• BNP increased to 617.9 pg/ml

• Thorax X-rays: increased cardiac silhouette

• Do not resuscitate agreement with the family