A 26-year-old man from India visits the clinic with complaints of feeling tired all the time and experiencing lack of energy for the past couple of weeks. He also complains of weakness and numbness of his lower limbs. He has been strictly vegan since the age of 18, including not consuming eggs and milk. He does not take any vitamin or dietary supplements. Physical examination reveals a smooth, red beefy tongue along with lower extremity sensory and motor deficits. What other finding is most likely to accompany this patient’s condition?
AUpper limb weakness
BPsychiatric symptoms
CDecreased visual acuity
DMicrocytic anemia
EAtaxia
A 28-year-old woman presents with weakness, fatigability, headache, and faintness. She began to develop these symptoms 4 months ago, and their intensity has been increasing since then. Her medical history is significant for epilepsy diagnosed 4 years ago. She was prescribed valproic acid, which, even at a maximum dose, did not control her seizures. She was prescribed phenytoin 6 months ago. Currently, she takes 300 mg of phenytoin sodium daily and is seizure-free. She also takes 40 mg of omeprazole daily for gastroesophageal disease, which was diagnosed 4 months ago. She became a vegan 2 months ago. She does not smoke and consumes alcohol occasionally. Her blood pressure is 105/80 mm Hg, heart rate is 98/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). Her physical examination is significant only for paleness. Blood test shows the following findings: Erythrocytes 2.5 x 109/mm3 Hb 9.7 g/dL Hct 35% Mean corpuscular hemoglobin 49.9 pg/cell (3.1 fmol/cell) Mean corpuscular volume 136 µm3 (136 fL) Reticulocyte count 0.1% Total leukocyte count 3110/mm3 Neutrophils 52% Lymphocytes 37% Eosinophils 3% Monocytes 8% Basophils 0% Platelet count 203,000/mm3 Which of the following factors most likely caused this patient’s condition?
AOmeprazole intake
BAlcohol intake
CEpilepsy
DPhenytoin intake
EVegan diet
A 36-year-old woman gravida 5, para 4 was admitted at 31 weeks of gestation with worsening fatigue and shortness of breath on exertion for the past month. She also has nausea and loss of appetite. No significant past medical history. The patient denies any smoking history, alcohol or illicit drug use. Her vital signs include: blood pressure 110/60 mm Hg, pulse 120/min, respiratory rate 22/min and temperature 35.1℃ (97.0℉). A complete blood count reveals a macrocytosis with severe pancytopenia, as follows: Hb 7.2 g/dL RBC 3.6 million/uL WBC 4,400/mm3 Neutrophils 40% Lymphocytes 20% Platelets 15,000/mm3 MCV 104 fL Reticulocytes 0.9% Serum ferritin and vitamin B12 levels were within normal limits. There was an elevated homocysteine level and a normal methylmalonic acid level. Which of the following is the most likely diagnosis in this patient?
ANormal pregnancy
BAplastic anemia
CVitamin B12 deficiency
DIron deficiency anemia
EFolate deficiency
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