ANSWER 52
A dietary history is an essential part of any history and is particularly important here where
a number of features point towards a possible nutritional problem. He has been a widower
for 5 years with no family support. He lives alone on a second-floor flat which may make
it difficult for him to get out. He has lost his dentures which is likely to make it difficult for
him to eat.
He has a petechial rash which could be related to coagulation problems, but the platelet count
is normal. It would be important to examine the rash carefully to see if it is distributed around
the hair follicles. A number of the features suggest a possible diagnosis of scurvyfrom vita-
min C deficiency. Body stores of vitamin C are sufficient to last 2–3 months. The rash, muscle
and joint pains and tenderness, poor wound healing and microcytic anaemia are all features
of scurvy. The classic feature of bleeding from the gums would not be present in an edentu-
lous patient.
Plasma measurements of vitamin C are difficult because of the wide range in normal sub-
jects. In this patient, replacement with ascorbic acid orally cleared up the symptoms within
2 weeks. It would be important to look for other nutritional deficiencies in this situation
and to make arrangements to ensure that the situation did not recur after his discharge
from hospital.
- A nutritional history should be part of any clinical assessment, particularly in the elderly.
- Vitamin deficiencies can occur in patients on a poor diet in the absence of any problem
with malabsorption.