Thank you Dr. Kahn for an interesting case of multiple myeloma in a patient presenting with chest pain.

Key Learning Points:

• Keep your chest pain differential broad and always look for the sinister 6 (emergency) causes of chest pain (ACS, Aortic dissection, PE, Tension pneumothorax, cardiac tamponade, and esophageal rupture).
• Protein gaps (Total protein – albumin) >4 are abnormal! Determine if monoclonal vs polyclonal first.
• Hyponatremia – confirm if true hyponatremia by checking serum osm. In this case, patient had a pseudohyponatremia from paraproteins.
• Remember CRAB presentation for multiple myeloma (hypercalcemia, renal dysfunction, anemia, bony pain).

High yield: Sensitivity of SPEP alone is ~80%. Adding UPEP or free light chains testing improves the sensitivity.