For Student

History
An 82-year-old man is sent up to the emergency department by his general practitioner (GP). He
is complaining of weakness and general malaise. He has complained of general pains in the
muscles and he also has some pains in the joints, particularly the elbows, wrists and knees. Three
weeks earlier, he fell and hit his leg and has some local pain related to this. He is a non-smoker
who does not drink any alcohol and has not been on any medication. Twelve years ago he had a
myocardial infarction and was put on a beta-blocker but he has not had a prescription for this in
the last 6 years. Twenty years ago he had a cholecystectomy. He used to work as a labourer until
his retirement at the age of 63 years. He lives alone in a second-floor flat. His wife died 5 years
ago. He has one son who lives in Ireland and whom he has not seen for 3 years.
Examination
He is tender over the muscles around his limb girdles and there is a little tenderness over the
elbows, wrists and knees. The mouth looks normal except that his tongue appears rather smooth.
He has no teeth and has lost his dentures. There are no other abnormalities to find in the
cardiovascular, respiratory or alimentary systems. In the legs, he has a superficial laceration on the
front of the right shin. This is oozing blood and has not healed. There is a petechial rash on some
areas of the legs. There are some larger areas of bruising on the arms and the legs which he says
have not been associated with any trauma.
Haemoglobin 10.1 g/dL (13.7–17.7 g/dL)
Mean corpuscular volume (MCV) 74 fL (80–99 f)
White cell count 7.9 % 109/L (3.9–10.6 % 109/L)
Neutrophils 6.3 % 109/L (1.8–7.7 % 109/L)
Lymphocytes 1.2 % 109/L (1.0–4.8 % 109/L)
Platelets 334 % 109/L (150–440 % 109/L)

Tasks:
1. What essential area of the history is not covered above?
2. What is the likely diagnosis?
Student’s name
For examiner
History
An 82-year-old man is sent up to the emergency department by his general practitioner (GP). He
is complaining of weakness and general malaise. He has complained of general pains in the
muscles and he also has some pains in the joints, particularly the elbows, wrists and knees. Three
weeks earlier, he fell and hit his leg and has some local pain related to this. He is a non-smoker
who does not drink any alcohol and has not been on any medication. Twelve years ago he had a
myocardial infarction and was put on a beta-blocker but he has not had a prescription for this in
the last 6 years. Twenty years ago he had a cholecystectomy. He used to work as a labourer until
his retirement at the age of 63 years. He lives alone in a second-floor flat. His wife died 5 years
ago. He has one son who lives in Ireland and whom he has not seen for 3 years.
Examination
He is tender over the muscles around his limb girdles and there is a little tenderness over the
elbows, wrists and knees. The mouth looks normal except that his tongue appears rather smooth.
He has no teeth and has lost his dentures. There are no other abnormalities to find in the
cardiovascular, respiratory or alimentary systems. In the legs, he has a superficial laceration on the
front of the right shin. This is oozing blood and has not healed. There is a petechial rash on some
areas of the legs. There are some larger areas of bruising on the arms and the legs which he says
have not been associated with any trauma.
Haemoglobin 10.1 g/dL (13.7–17.7 g/dL)
Mean corpuscular volume (MCV) 74 fL (80–99 f)
White cell count 7.9 % 109/L (3.9–10.6 % 109/L)
Neutrophils 6.3 % 109/L (1.8–7.7 % 109/L)
Lymphocytes 1.2 % 109/L (1.0–4.8 % 109/L)
Platelets 334 % 109/L (150–440 % 109/L)
Task 1 (5.0) 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.
Task 2 (5.0) 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
scurvy from vitamin 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
edentulous patient. Plasma measurements of vitamin C are difficult because of the wide range in
normal subjects. 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.

Final score: