A 72-year-old man is brought into the hospital by paramedics after he was found disoriented and wandering in the street. He has a past medical history of dementia, hypertension, and stroke. Physical examination reveals a disoriented, thin-appearing male. His gingivae are swollen and bleed easily. Ecchymoses are noted on his legs. The laboratory values are provided below: Which of the following is most likely responsible for this patient's ecchymoses?

Question

A 72-year-old man is brought into the hospital by paramedics after he was found disoriented and wandering in the street.  He has a past medical history of dementia, hypertension, and stroke.  Physical examination reveals a disoriented, thin-appearing male.  His gingivae are swollen and bleed easily.  Ecchymoses are noted on his legs.  The laboratory values are provided below:  Which of the following is most likely responsible for this patient's ecchymoses?

Quizplus · Accepted Answer

Vitamin C (ascorbic acid) is a water soluble vitamin that functions as a cofactor in numerous biochemical processes, including collagen synthesis. Deficiency in vitamin C ("scurvy") is most commonly due to insufficient intake, which tends to occur in the setting of chronic drug or alcohol abuse, malnourishment, or old age. Cutaneous signs of scurvy include phrynoderma (perifollicular hyperkeratosis), coiled hair, and poor wound healing. Mucosal findings include bleeding gums and loose teeth. Hemorrhagic complications include ecchymoses and petechiae, hemarthrosis, intramuscular bleeding, and bleeding within the central nervous system, gastrointestinal tract, and genitourinary system. Normocytic, normochromic anemia is typical, while coagulation studies (including PT and PTT) are normal. Treatment is with vitamin C supplementation, and symptomatic improvement is expected within days. (Choice A) Common causes of platelet dysfunction in the elderly include uremia and NSAID use. This patient has mild dehydration and prerenal azotemia, which should not cause platelet dysfunction. Similarly, while this patient might be taking aspirin because of his stroke history, aspirin alone would not cause bleeding gums. (Choice B) Endothelial cell dysfunction can cause von Willebrand disease. However, this condition typically presents earlier in life and is associated with a prolonged PTT. (Choice C) Hepatic dysfunction can cause prolongation of both PT and PTT or prolongation of PT with a normal PTT. This patient has a normal PT and PTT. (Choice E) Deficiency in vitamin K (a fat soluble vitamin) results in a prolonged PT. (Choice F) Zinc deficiency is characterized by an erosive dermatitis of the hands and feet and the perioral, perianal and periocular regions. Other findings include diarrhea, conjunctivitis, and impaired wound healing. Educational objective: Vitamin C deficiency (scurvy) is associated with coiled hair, perifollicular keratosis, hemorrhage, easy bruising, bleeding gums, and loose teeth. The PT, PTT, and platelet count are normal.

A 72-Year-Old Man Is Brought into the Hospital by Paramedics After