Case Four

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A 74 year old Vietnam veteran presents to clinic to re-establish care. He reports several months of worsening fatigue, weight loss, and nocturia. He also reports severe low back pain after a fall last week, requiring that he ambulate with a walker.

His exam is notable for lumbar spinal tenderness. Labs show WBC 4.5, Hb 9.6, and platelets 82,000. Calcium is elevated to 10.5. Lumbar x-ray showed multiple spinal lesions.

You send a smear, which shows the following.