Vitamin B12 deficiency Quiz: Ace Your Exams

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A 43-year-old woman presents to the primary care office for follow-up of vitamin B12 deficiency. She has been receiving 1,000 mcg of vitamin B12 intramuscularly weekly for three weeks. She continues to have the same symptoms of numbness in her hands and feet and fatigue that were present at the initial presentation.  She had a Roux-en-Y gastric bypass four years ago. Temperature is 37.0°C (98.6°F), pulse is 102/min, respiratory rate is 20/min, and blood pressure is 110/82 mmHg. Conjunctivae appear pale and examination of the mouth reveals glossitis. Tachycardia and a systolic flow murmur are present on cardiac exam. Deep tendon reflexes are 2/4 in all extremities. Romberg test is negative. Sensation to light touch is diminished below the knees bilaterally. Laboratory results can be seen below. Which of the following is the next best step in management?  

 Laboratory value  Results from 3 weeks prior  Result from  today 
 Hemoglobin  10.1 g/dL  10.2 g/dL 
 MCV  109 fL  108 fL 
 Vitamin B12  127 pg/mL  263 pg/mL 
 MMA  (reference range 0 - 400 nmol/L)  451 nmol/L  455 nmol/L 

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