Review Question - QID 109536

This patient is presenting with symptoms of Wernicke's encephalopathy (thiamine deficiency), clotting abnormalities (vitamin K deficiency), fractures (vitamin D deficiency), hyperkeratosis (vitamin A deficiency), and some signs of scurvy (vitamin C deficiency), suggesting a diagnosis of malnutrition.

Malnutrition typically occurs in vulnerable populations including the elderly, those with dementia, the handicapped, and those who are unable to care for themselves. The differential diagnosis should include elder abuse, alcohol abuse, and other pathologies that could result in malabsorption (Crohn's and Celiac disease). The best initial step in management is to replete nutrients and to discharge the patient with a care plan that ensures that they are taken care of.

Figure A demonstrates hyperkeratosis of the hands which can occur with vitamin A deficiency. Figure B shows a compression fracture of the fourth lumbar vertebra which can occur with trauma or in patients who are vitamin D deficient or suffer from osteoporosis.

Incorrect Answers:
Answer 1: Elder abuse would present with abnormal bruises and fractures as this patient has. However, this would not explain this patient's other symptoms. In the setting of a patient with dementia living alone, malnutrition is a more likely diagnosis.

Answer 2: Alcohol abuse could present with thiamine deficiency which could predispose a patient to Wernicke-Korsakoff encephalopathy. Notably, this patient's lack of history of alcohol use and his old age combined with dementia and living alone suggest a diagnosis of malnutrition secondary to poor oral intake.

Answer 3: Celiac disease could present with symptoms of fat soluble vitamin deficiencies; however, it would be unlikely that such symptoms would present so late in life.

Answer 5: Normal aging does not present with multiple deficiencies in different vitamins.

Bullet Summary:
Malnutrition presents with symptoms suggestive of multiple different vitamin and mineral deficiencies and tends to occur in vulnerable populations such as the elderly, those with dementia, and handicapped individuals.