Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a history of progressive fatigue, generalized weakness, and exertional dyspnea. Reports associated symptoms of paresthesia in distal extremities, gait instability, and cognitive "fog." Denies hematochezia or melena. Dietary history significant for [Vegan/Vegetarian/Strict Diet]. No prior history of gastric surgery or malabsorption syndromes.
Clinical Examination Findings
General: Pale conjunctiva and skin pallor noted. HEENT: Glossitis with smooth, beefy-red tongue. Cardiovascular: Tachycardia with flow murmur. Neurological: Diminished vibration sense and proprioception in lower extremities; positive Romberg sign; hyperreflexia or diminished reflexes noted in lower limbs.
Treatment Protocol
Initiate Vitamin B12 replacement therapy: Cyanocobalamin 1000 mcg IM injection daily for 1 week, followed by weekly injections for 4 weeks, then monthly maintenance. Monitor reticulocyte count in 7-10 days. Evaluate for underlying etiology (e.g., pernicious anemia, dietary deficiency, or malabsorption).