Why Vitamin B12 Deficiency Should be on your Radar Screen

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<strong>Vitamin</strong> <strong>B12</strong> <strong>Deficiency</strong> Case Study Question 2 What risk factors does this woman appear to have for a vitamin <strong>B12</strong> deficiency? Physical Examination Pale 65 y.o. WF who appears well-nourished, alert, and oriented. Vital Signs T-98.6, HR-76, R-18, B/P-130/80 supine and 95/52 upon standing, Height/Weight 5’4”/120 lbs. Head Normocephalic; oropharynx clear but pale; palpebral conjunctivae pale. Neck Supple, full active and passive ROM without pain, without audible bruits; no lymphadenopathy; no thyromegaly Back No spine tenderness Lungs Clear to auscultation Heart Regular rate and rhythm; no murmurs Abdomen Soft, nontender; no organomegaly Rectal Normal rectal tone; no fissures Extremities No clubbing, cyanosis, or edema; FROM Skin Pale; no rash The general physical examination is unremarkable except for orthostatic hypotension and a weight loss of 3 pounds since her last visit 6 months ago. She is alert and oriented times three. Her Mini-Mental Status Exam score is 26 out of 30. She misses one point on serial 7s and is able to recall three of three items. There is evidence of bilateral mildly diminished vibration and proprioception. Her reflexes are 3+/4+ throughout, with negative Babinski reflex. Cranial II—Visual acuity 20/25 in both eyes Nerves (corrected); normal fundoscopic examination; visual fields intact with no central scotoma III, IV, VI—Extraocular movements intact; pupils equal, round, and reactive to light with no afferent pupillary defect V, VII, XII—Intact facial sensation; intact 7
<strong>Vitamin</strong> <strong>B12</strong> <strong>Deficiency</strong> masseter motor strength, without dysarthria; tongue protruded in midline VIII—Hearing grossly normal XI, X—Swallowing intact XI—Muscle strength equal bilaterally Motor Normal muscle bulk; muscle strength 5/5 in all muscle groups Cere<strong>be</strong>llar Normal finger-to-nose, heel-to-shin, and rapid alternating movements Case Study Questions 3. Does the fact that she appears to <strong>be</strong> “well-nourished” indicate she is unlikely to have a vitamin deficiency? <strong>Why</strong> or why not? 4. Are there any aspects of her physical examination that suggest a vitamin <strong>B12</strong> deficiency? 5. Given her history and physical examination findings, what laboratory test(s) would you order? Laboratory Studies You order routine laboratory studies, which include complete blood count (CBC) with smear and chemistry screen. In addition, you order a serum vitamin <strong>B12</strong> level to investigate further the etiology of her fatigue and pale mucosa. Results from the CBC and smear reveal a borderline macrocytic anemia. The chemistry panel is within normal limits. The serum vitamin <strong>B12</strong> level you requested is 215 picograms per milliliter (pg/mL). This level is considered within a “normal range” by some laboratories, but you take into account her other signs and symptoms and request confirmatory testing with 8
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Why Vitamin B12 Deficiency Should be on your Radar Screen

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