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Old 11-01-2012
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Arrow Gyrus Daily Questions; Internal Medicine #64

A 76-year-old man is brought to the office by his son, who states that his father has been forgetful over the last few months and keeps asking the same questions again and again The patient complains of increasing, generalized weakness, fatigue. as well as a tingling sensation on the lower extremities His appetite is unchanged and he maintains a balanced diet Vital signs are T 37 5 °C (99 5 °F). blood pressure 140/90 mm Hg. and pulse 90/min The patient appears somnolent but is oriented to time, place and person. HEENT conjunctiva mildly icteric. red, smooth tongue is observed Heart: regular rate and rhythm. with an S1 and S2. a systolic ejection murmur is heard Abdomen is mildly distended Neurologic exam: muscle strength 4/5 throughout. loss of position and vibration sense in lower extremities. ataxic gait Laboratory reports include

Hemoglobin 10 gm/dl
Platelets 190.000/mm 2
White blood cells 4000/mm 2
Differential Granulocytes 60% Lymphocytes 30% Monocytes 5%
MCV 110 um
MCHC 35%
MCH 33 6 pg/cell
TSH 3 pU/mL (0 5-5 pU/mL)

Urine methylmalonate: increased

After confirming the diagnosis of this patient's condition, which of the following should be considered in his future evaluafion ?

a. Calcium
b. Fasting blood glucose
c. Folic acid
d. Gastrin level
e. Plasma Homocysteine
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Old 11-01-2012
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Would be A?

thinking autoimmune right now
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Old 11-01-2012
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d. Gastrin level

Since you are looking for the cause of his anemia despite a balanced diet.
Pernicious anemia (caused by atrophic gastritis, parietal cell loss, and lack of intrinsic factor) would be high on the list since you need acidic pH to get rid of the carrier protein from B12 in order for it to be absorbed after binding to IF.
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Last edited by Novobiocin; 11-01-2012 at 04:41 PM.
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