Clinical BCQ Challenge — VITAMIN DEFICIENCY SYNDROMES — FOCUSED CLINICAL EXAMINATION

MS Module — Clinical Long & Short Cases | Final Year MBBS

FINAL YEAR MBBS • KMU CURRICULUM • AIM CLINICAL LEARNING

🔎 Short Case Clinical BCQ Challenge

VITAMIN DEFICIENCY SYNDROMES — FOCUSED CLINICAL EXAMINATION

10 A-Type Single Best Answer BCQs • Focused Bedside Clinical Application

🎯 Purpose of This Clinical Challenge

Apply the findings from this Short Case to focused Final Year clinical problems involving clinical sign recognition, interpretation, diagnosis, differential diagnosis, relevant investigations and immediate clinical decisions.

🧠 How to Approach the BCQs

Clinical Sign Interpretation Diagnosis Differential Investigation

Focus on the bedside finding, interpret its clinical significance and select the single best answer.

AIM SHORT CASE ASSESSMENT

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Short Case • Bedside Recognition • Single Best Answer

Welcome to your 🔎 SHORT CASE 1 — Vitamin Deficiency Syndromes — Focused Clinical Examination 1.

A 48-year-old man with poor nutritional intake has an unsteady gait. Examination reveals impaired vibration and joint position sense in both feet with a positive Romberg test. Which neurological dysfunction best explains these findings?

Cerebellar hemisphere dysfunction

Corticospinal tract dysfunction

Posterior column dysfunction

Vestibular apparatus dysfunction

Anterior horn cell dysfunction

None

A patient with suspected nutritional neuropathy stands steadily with his eyes open but becomes markedly unstable when he closes them. What is the most appropriate interpretation of this examination finding?

Impaired proprioceptive sensory input

Impaired cerebellar motor coordination

Reduced vestibulo-ocular reflex activity

Bilateral proximal muscle weakness

Increased lower limb muscle tone

None

A 52-year-old woman with chronic malabsorption presents with progressive gait instability. Examination reveals absent ankle reflexes, impaired position sense and limb incoordination. Which additional finding would most strongly suggest vitamin E deficiency?

Bilateral pitting pedal edema

Recurrent spontaneous ecchymoses

Tenderness over the tibial shafts

Dry conjunctiva with Bitot spots

Reduced deep tendon reflexes with ataxia

None

A 50-year-old man who underwent gastric surgery presents with progressive numbness in both feet and difficulty walking. Examination reveals glossitis, impaired joint position sense and sensory ataxia. What is the most likely diagnosis?

Vitamin B1 deficiency with dry beriberi

Vitamin B12 deficiency with neurological involvement

Vitamin B6 deficiency with peripheral neuropathy

Vitamin D deficiency with osteomalacia

Vitamin K deficiency with coagulopathy

None

A malnourished patient presents with bilateral ankle edema, tachycardia and distal lower limb sensory loss. Examination suggests both cardiovascular dysfunction and peripheral neuropathy. Which vitamin deficiency most likely explains this combination?

Vitamin B12 deficiency

Vitamin E deficiency

Vitamin B6 deficiency

Vitamin B1 deficiency

Vitamin D deficiency

None

A 45-year-old woman presents with difficulty rising from a chair and diffuse bone pain. Examination reveals proximal muscle weakness and tenderness over the tibiae without significant sensory loss. Which diagnosis best explains these findings?

Osteomalacia due to vitamin D deficiency

Peripheral neuropathy due to vitamin B6 deficiency

Sensory ataxia due to vitamin E deficiency

Subacute combined degeneration due to vitamin B12 deficiency

Dry beriberi due to vitamin B1 deficiency

None

A 42-year-old man with chronic malabsorption presents with progressive difficulty walking in dim light. Examination demonstrates impaired joint position sense, absent ankle reflexes and an ataxic gait. His hemoglobin and mean corpuscular volume are normal. Which finding would most strongly favor vitamin B12 deficiency over vitamin E deficiency?

Bilateral reduction in ankle reflexes

Impaired vibration sense in both feet

Unsteadiness during tandem walking

Reduced joint position sense at the toes

Positive serum anti-intrinsic factor antibodies

None

A 47-year-old man has progressive bilateral foot numbness and an unsteady gait. Examination reveals impaired proprioception, but he also has a definite thoracic sensory level and new urinary retention. Which alternative diagnosis must be urgently considered?

Vitamin A deficiency

Compressive spinal cord lesion

Vitamin B6 deficiency

Nutritional peripheral neuropathy

Vitamin E deficiency

None

A 55-year-old woman presents with glossitis, distal numbness and sensory ataxia. Her serum vitamin B12 concentration is borderline. Which investigation would most directly support functional vitamin B12 deficiency?

Serum alkaline phosphatase

Prothrombin time

Serum 25-hydroxyvitamin D

Serum methylmalonic acid

Serum calcium concentration

None

10.

A 49-year-old man with previous gastric surgery presents with progressive sensory ataxia, impaired vibration sense and glossitis. Vitamin B12 deficiency is strongly suspected, and neurological deterioration is continuing. What is the most appropriate immediate management principle?

Begin oral folic acid without vitamin B12 replacement

Delay treatment until neurological imaging is completed

Initiate prompt vitamin B12 replacement

Recommend dietary modification without supplementation

Observe for spontaneous neurological improvement

None

Time's up

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Think like a bedside examiner: clinical sign → interpretation → diagnosis → differential → relevant investigation.

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