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Chief Complaint

“My thinking seems cloudy and I’m always tired. It’s been busy at work, but lately I’ve had headaches and yesterday I was so dizzy I had to sit down.”

History of Present Illness

Camille Jones is a 34-year-old white female who presents to her primary care provider with complaints of fatigue and cloudy thinking over the past 4-5 months and more recently headaches and dizziness. She feels slow when completing tasks at work and notes she stopped her longstanding routine of swimming three days weekly before work due to exhaustion.

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Missing Information?


Patient Database

Drug Therapy Problems

Care Plan (by Problem)


  1. What symptoms of anemia are present in this patient?

    Hint: See Epidemiology and Etiology and Treatment in PPP

  2. What laboratory findings would confirm this patient’s type of anemia?

    Hint: See Treatment and Figure 69-4 in PPP

  3. What is the likely etiology of this patient’s anemia?

    Hint: See Treatment and Figure 69-4 in PPP

  4. How should this patient’s anemia be treated?

    Hint: See Treatment in PPP

  5. What monitoring parameters are recommended after treatment is initiated?

    Hint: See Treatment in PPP


One year later Camille asks if she can take an over-the-counter medication for acid reflux that tends to occur after she eats spicy foods. What would you recommend?

Hint: See Table 18-2 in PPP


Global Perspective

Macrocytic anemia caused by micronutrient deficiencies occurs worldwide in those suffering from malnutrition. Vitamin B12 is available from a variety of animal sources, including dairy products, eggs, fish, meat, and poultry; however, populations without ready access to these foods and who instead rely on plant sources for the majority of their caloric intake may develop deficiencies. Malabsorption of vitamin B12 is more often the cause of deficiency in advanced nations, in which dietary ingestion is generally sufficient. According to the 2013 to 2016 National Health and Nutrition Examination Survey (NHANES), only 8% of women and 3% of men did not consume the estimated average requirement of vitamin B12. Yet vitamin B12 deficiency affects between 1.5% and 15% of the United States population. Malabsorption of vitamin B12 is especially common in older people due to atrophic gastritis and subsequent reduced levels of gastric acid secretion, but it is also noted following gastric surgical procedures, in those with GI disorders such as Crohn’s and celiac disease, and in patients with pernicious anemia. In addition, prolonged acid suppression therapy has been recognized as a cause of decreased vitamin B12 absorption, although the clinical significance of this finding is debated.


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