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A 67-year-old female presents to your clinic complaining of fatigue, diarrhea, headaches and a loss of appetite. Upon examination you find that she is having some cognitive difficulty. Laboratory results reveal: MCV: 109fL; Hgb: 9g/dL; MMA and homocystine are both elevated. Shilling test is positive.
What is the next best step in the management of this patient?
Suggested Answer: C
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A fasting blood glucose level of greater than 7 mmol/L (or greater than 126mg/dL) is an indicator of type 2 diabetes.
43 comments · newest first
AS
Ashlee
10 months ago
I thought folic acid was the answer... why B12?
EV
Evelynn
11 months ago
Elevated MMA and homocysteine? B12 is the way to go!
SU
Suzan
11 months ago
Wait, is it really lifelong? That seems extreme.
IL
Iluminada
11 months ago
Definitely B12 supplementation! Can't go wrong there.
RO
Robt
11 months ago
Sounds like a classic case of B12 deficiency.
GL
Glennis
12 months ago
I thought the Shilling test was used to determine absorption issues, but I can't remember if that changes the treatment approach. Is it really just B12 for life?
VI
Vilma
12 months ago
This case seems similar to one we practiced where cognitive issues were linked to anemia. I think the management was also focused on B12.
HO
Hobert
12 months ago
I'm a bit unsure about the Shilling test results. Does a positive result definitely mean we should go with B12 supplementation?
JE
Jess
1 year ago
I remember that elevated MMA and homocysteine levels indicate a vitamin B12 deficiency, so I think the answer might be lifelong Vitamin B12 supplementation.
DE
Devora
1 year ago
Okay, I've got this. The key findings are the megaloblastic anemia and malabsorption, so the logical next step is to provide the patient with lifelong B12 supplementation. That should address the underlying deficiency and help resolve the symptoms. I feel pretty confident about this one.
LO
Louis
1 year ago
Hmm, this is a tricky one. The cognitive issues have me a bit stumped. I'm leaning towards the B12 supplementation, but I'm also wondering if there could be an autoimmune component that would warrant the Coombs test. I'll have to weigh the options carefully.
FR
Francisca
1 year ago
Okay, let me think this through step-by-step. The key lab findings are the elevated MMA and homocystine, which point to a B12 deficiency. And the positive Shilling test confirms malabsorption. So I think the best approach is to go with lifelong B12 supplementation to address the root cause.
DE
Delisa
1 year ago
I'm a bit unsure about this one. The cognitive difficulties and diarrhea make me wonder if there could be another underlying issue beyond just a B12 deficiency. Maybe I should consider the other options like folic acid or iron supplementation as well.
AR
Arlie
1 year ago
Hmm, this seems like a classic case of vitamin B12 deficiency. The elevated MCV, low Hgb, and positive Shilling test are all telltale signs. I'm pretty confident that the next best step is lifelong B12 supplementation.
CA
Carmen
1 year ago
Okay, I've got this. Contour, Harbor, and Velero - those are the three open source projects included in Tanzu Kubernetes Grid. I'm confident about those choices.
LO
Lorean
1 year ago
Hmm, this one seems tricky. I'll need to think carefully about which editors can and can't be modified with a custom stencil.
RU
Rueben
1 year ago
Hmm, I'm a bit unsure about this one. The wording is a bit tricky, and I want to make sure I understand exactly what they're asking. I'll re-read the question and the options a few times to make sure I don't miss anything.
LA
Latrice
1 year ago
Okay, let me think this through. FTP, SSH, and SMTP are all different network protocols, but none of them specifically translate between host names and IP addresses like the question is asking. I'm pretty sure DNS is the right choice here.
LO
Loreta
1 year ago
Folic acid? Really? That's like trying to put out a fire with gasoline. This is a classic B12 deficiency, no question about it. Time to get that lady some serious B12 action!
DY
Dyan
1 year ago
The poor lady's got some serious cognitive issues. Maybe we should try to fix that first before worrying about the diarrhea and headaches, eh? B12 all the way, my friends.
HA
Harris
1 year ago
I agree, let's go with B) Lifelong Vitamin B12 supplementation as the next best step in management.
KA
Kaitlyn
1 year ago
True, but B12 deficiency can lead to neurological symptoms, so it's important to address that first.
CO
Cornell
1 year ago
But what about the other symptoms like fatigue and diarrhea? Shouldn't we consider other options?
TE
Terina
1 year ago
I think we should start with B12 supplementation to address the cognitive issues.
CA
Carmelina
1 year ago
Haha, corticosteroids and iron? What is this, a twofer special? Definitely not the right answer. B12 is the way to go, no doubt about it.
KA
Kayleigh
1 year ago
I've seen cases like this before, B12 is the way to go for sure.
AN
Annette
1 year ago
Yeah, B12 deficiency can cause all those symptoms. Lifelong supplementation is key.
SH
Shannan
1 year ago
I agree, B12 supplementation is definitely the next best step.
MA
Makeda
1 year ago
I'm not sure about the Coomb's test here. Isn't that for hemolytic anemia? This seems more like a malabsorption issue. I'd go with the B12 supplementation.
ST
Stephaine
1 year ago
This is clearly a case of pernicious anemia. The elevated MMA and homocystine, along with the positive Shilling test, point to a vitamin B12 deficiency. Lifelong B12 supplementation is the way to go.
ST
Stephane
1 year ago
Definitely. Lifelong B12 supplementation is the best management for this patient.
IV
Ivan
1 year ago
So, the positive Shilling test confirms pernicious anemia.
CH
Chu
1 year ago
User 3: Lifelong B12 supplementation is definitely the way to go in this case.
ST
Stevie
1 year ago
Yes, I agree. The elevated MMA and homocystine levels indicate a vitamin B12 deficiency.
ST
Stanton
1 year ago
User 2: I agree, the elevated MMA and homocystine levels point to a vitamin B12 deficiency.
JU
Julian
1 year ago
I think the next best step is lifelong Vitamin B12 supplementation.
AL
Aleisha
1 year ago
User 1: I think the next best step is lifelong Vitamin B12 supplementation.
KI
Kiera
1 year ago
I'm not sure, but I think A) Lifelong folic acid supplementation could also be a good option.
SE
Serina
1 year ago
I agree with Alecia, Vitamin B12 supplementation is important for this patient.
AL
Alecia
2 years ago
I think the next best step is B) Lifelong Vitamin B12 supplementation.
DO
Dorathy
2 years ago
I'm not sure, but I think A) Lifelong folic acid supplementation could also be a good option.
TH
Thora
2 years ago
I agree with Marcelle, Vitamin B12 supplementation is important for this patient.
MA
Marcelle
2 years ago
I think the next best step is B) Lifelong Vitamin B12 supplementation.