1. Nikita Alicea

2. DIAGNOSIS
Essential cofactor of methylation process of DNA & cell metabolism
Also referred to as cobalamin
Myelin synthesis & repair, RBCs formation
Deficiency causes megaloblastic anemia, damage to white matter of the spinal cord and brain, and peripheral neuropathy

3. ICD-10 CODES Other dietary vitamin B12 deficiency anemia D51.3
Other vitamin B12 deficiency anemias
D51.9
Vitamin B12 deficiency anemia, unspecified

4. PATHOGENESIS Gradual onset usually after age of 60
Higher rates among European & African descents (4% to 4.3%)
Causes:
Malabsorption of vitamin B12
Pernicious anemia
Impaired ileal uptake
Dietary deficiency

5. CLINICAL MANIFESTATIONS
HISTORY
Presentation:
Ages any age group
Sore tongue, numbness & tingling pf extremities
Weakness, dizziness, diarrhea, constipation
Dyspnea on exertion, palpitations
Abdominal tenderness, dementia

6. CLINICAL MANIFESTATIONS
HISTORY
ROS & Health History:
Onset, duration and course of symptoms
Usual bowel habits, blood in stool
24 hour recall of dietary intake
Pins & needles paresthesia
Weakness, fatigue & lethargy
Alcohol consumption
Medications; Rx. & OTC
Past medical history
Surgical history; Gastrectomy, resection of ileum
Autoimmune disorders

7. CLINICAL MANIFESTATIONS
PHYSICAL EXAM
Vital signs, weight & height – Weight loss
Overall appearance- Premature aging
Oral examination- Glossitis
Eye and dermal examination- Icteric
Heart, lungs & abdomen auscultation
Abdominal palpation & percussion
DTRs & mental status examination
Finger nose coordination – Poor
Romberg’s & Babinski’s sign - Positive

8. CLINICAL MANIFESTATIONS

9. DIAGNOSTIC TESTS CBC with differential Peripheral smear
Serum B12 level
Serum methlymalonic acid
Anti intrinsic factor antibodies
Anti parietal cell antibodies

10. DIFFERENTIAL DIAGNOSES
DIFFERENTIALS RED FLAGS
Folic Acid Deficiency Myelodysplasia
Aplastic Anemia Acute Hemolysis
Chronic liver disease or Hemorrhage
Hypothyroidism with brisk reticulocytosis

11. TREATMENT Vitamin B12 IM or Sub-q injections 100 mcg
Daily for a week, weekly for a month, then monthly for life
Oral methylcobalamin 1mg/day for life
Serum B12 monitoring
Patient Education-Life long therapy
Precautions
Follow up

12. OUTCOMES
Patients are able to live normal healthy life and maintain daily activities
Symptoms are reversible with adherence to medication therapy
Regular follow up is important

13. REFERENCES
Hunt A Harrington D Robinson S 2014 Clinical review; Vitamin B12 deficiency.Hunt, A., Harrington, D., & Robinson, S. (2014). Clinical review; Vitamin B12 deficiency. BMJ, 349, 1-10.
Cash J C Glass C A 2014 Family Practice GuidelinesCash, J. C., & Glass, C. A. (2014). Family Practice Guidelines (3 ed.). New York, NY: Springer Publishing Company
Papadakis M A McPhee S J Rabow M W 2016 Current medical diagnosis & treatmentPapadakis, M. A., McPhee, S. J., & Rabow, M. W. (2016). Current medical diagnosis & treatment (55 ed.). New York, NY: McGraw-Hill Education
Goroll A H Mulley A G 2014 Primary care medicineGoroll, A. H., & Mulley, A. G. (2014). Primary care medicine (7 ed.). Philadelphia, PA: Lippincott Williams & Wilkins
Stabler S 2013 Clinical practice; Vitamin B12 deficiency.Stabler, S. (2013). Clinical practice; Vitamin B12 deficiency. The New England Journal of Medicine, 368,