OsteoEd

Practice Cases

Vitamin D Deficiency

Heidi Powell, MD Literature reviewed July 31, 2006. Updated June 22, 2009

A 70-year-old white man presents to you with right hip pain after a fall at home. At baseline, he has a mild right hemiparesis from a stroke. You gather the following information:

  • Medications:
    • Atenolol 50 mg daily
    • aspirin 325 mg daily
    • simvastatin 20 mg at bedtime
  • Past Medical History:
    • Hypertension
    • hyperlipidemia
    • macular degeneration
    • cerebral vascular accident
    • history of sub-total gastrectomy
  • Social History:
    • He lives alone and ambulates in the house with the help of a walker.
    • His son shops for him once a week.
  • Focused Exam:
    • There is a large, tender echymosis in the right trochanteric region.
    • He has moderate pain with abduction and adduction of his right hip.

His hip X-ray shows diffuse osteopenia but no fracture.

Click an answer under each question.

  1. Which of these conditions may be causing your patient's osteopenia?

  2. What risk factor(s) for osteomalacia does your patient have?

    • Option A Medications
    • Option B Vitamin D deficiency due to inadequate exposure to sunlight
    • Option C Decreased vitamin D and calcium absorption
    • Option D Vitamin D deficiency due to inadequate exposure to sunlight and decreased vitamin D and calcium absorption

  3. What age-related changes might contribute to vitamin D deficiency?

    • Option A Decreased absorption of dietary vitamin D
    • Option B Decreased skin production of previtamin D
    • Option C Reduced hydroxylation in the liver and kidney
    • Option D All of the above

  4. Which of the following are important natural food sources of vitamin D?

  5. What form of vitamin D most accurately reflects body stores?

  6. What laboratory results do you expect to find in this patient?

    • Option A Normal calcium, high phosphate, low parathyroid hormone levels
    • Option B Normal calcium, normal or low phosphate, high parathyroid hormone levels
    • Option C Low calcium, high phosphate, low parathyroid hormone levels
    • Option D High calcium, low phosphate, high parathyroid hormone levels

  7. You obtain the following tests and results:

    Test Result Normal Range
    25-OH vitamin D3 7.0 ng/mL 20.0 to 50 ng/mL
    Parathyroid hormone 105 pg/mL 8 to 78 pg/mL
    Calcium 9.0 mg/dL 8.9 to 10.2 mg/dL
    24-hour urine calcium 40 mg 50 to 300 mg

    Electrolytes, blood urea nitrogen, creatinine, albumin, liver transaminases, thyroid-stimulating hormone, complete blood count, and testosterone are normal. These results confirm that he has a vitamin D insufficiency and poor calcium absorption with secondary hyperparathyroidism. You start him on 1,500 mg of elemental calcium per day.

    Which treatment would you recommend at this time?

    • Option A Calcitonin nasal spray, 400 IU/day
    • Option B Ergocalciferol, 50,000 IU once a week for 8 weeks
    • Option C Alendronate, 10 mg/day
    • Option D Calcitriol, 0.25 mcg/day
Key Points
Last edited June 22, 2009