Answer to Q14: a

This is a patient who has diabetes (random glucose >200 on 2 occasions) telling us that he has pancreatic endocrine deficiency. The contracture in his hand is Dupuytren's contracture and this is typically associated with alcoholism (although this may be an inherited deformity in some patients). Dupuytren's contracture with multiple episodes of abdominal pain and evidence of liver disease (spider nevi in a male) should lead to the diagnosis of alcohol related cirrhosis and chronic pancreatitis due to alcohol.

Lack of pancreatic enzymes leads to steatorrhea. The patient will have fat malabsorption which in turn will lead to malabsorption of fat soluble vitamins.

Night blindness is due to Vitamin A deficiency. Vitamin A is a fat soluble vitamin as are Vitamins D, E & K (ADEK).

On the other hand Vitamin B & C are water soluble.

Scurvy is due to Vitamin C deficiency and is found in the elderly who live alone and are constantly eating frozen packs of food or not even that.

Pellagra is associated with Niacin deficiency. This is Vitamin B3(although in real terms it is not a vitamin as it can be synthesized in the human body utilizing tryptophan). It is water soluble and would not be deficient with fat malabsorption. Patients who get this deficiency are those who live in countries where maize is a major component of diet. In the developed world it may present in patients who have either HARTNUP's disease or those with CARCINOID.