Vitamin B12 deficiency Quiz: Ace Your Exams
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An 83-year-old woman presents to the primary care office with two months of fatigue and tingling in her hands and feet. She has also had difficulty focusing on routine tasks and has been forgetful. She has no chest pain, nausea, diarrhea, or abdominal pain. Past medical history is significant for gastroesophageal reflux. Past surgical history is significant for an esophageal dilation for a stricture four years ago. She has been taking omeprazole daily for the past 20 years. She does not smoke or consume alcohol, and she eats a varied diet of fruits, vegetables, eggs, fish, and dairy. Temperature is 37.0°C (98.6°F), pulse is 106/min, respiratory rate is 18/min, and blood pressure is 102/72 mmHg. BMI is 38. Eye exam reveals conjunctival pallor. A systolic flow murmur is noted on cardiac exam. There is impaired sensation to fine touch and pinprick distally in all extremities. Laboratory studies are shown below. Which of the following is the most likely underlying cause of this patient’s condition?
| Laboratory value | Result | Reference range |
| Hemoglobin | 10.2 g/dL | 12-16 g/dL |
| Hematocrit | 32% | 36-46% |
| MCV | 108 fL | 80-100 fL |
| Methylmalonic acid | 480 nmol/L | 0 - 400 nmol/L |
| Homocysteine | 51 μmol/L | 5 - 15 μmol/L |
| Vitamin B12 | 164 pg/mL | 190-950 pg/mL |
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