GUESS THAT DIAGNOSIS: Numbness, Tingling, and Mild Confusion
QUICK OVERVIEW ABOUT PATIENT:
A 66 year old patient comes in with complaints of numbness and tingling in their fingers and toes. This patient also complains about some mild confusion. This has been ongoing for the last 11 months.
Review of systems: She complains of numbness and tingling in upper and lower extremities. She has had some mild confusion and forgetfulness that has been increasing over the last several months. She denies any unilateral weakness, facial droop, falls, dysphagia. She denies any fever, chills, chest pain, shortness of air, nausea, vomiting, abdomen pain.
Family history: Heart disease. Denies family hx of dementia, parkinsons, strokes
Surgical history: Includes gastric bypass, appendectomy, and tonsillectomy. Denies any back surgeries
Lifestyle: Former smoker (quit 3 yrs ago), recently went vegetarian 11 months ago, social ETOH use (1-2 times a month), good social support
Medications: Protonix, Claritin, Metformin, Spironolactone, Lisinopril
Medical history: Seasonal Allergies, GERD, PCOS, hypertension
Physical exam (just abnormal finds listed): Decreased sensation to vibration, generalized pale appearance, positive Romberg test, angular cheilitis, mild cognitive impairment-forgetful
Labs: CBC: elevated MCV, low hematocrit, Chemistry: normal, TSH normal, A1C normal, B12 low
Imaging: CT head normal, CXR normal, Carotid Doppler normal
WHAT IS THE MOST LIKELY DIAGNOSIS?
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ANSWER
B12 DEFICIENCY
RISK: Gastric bypass history, vegan or vegetarian diet, PPI and or Metformin use.
Complaints: Numbness & tingling in extremities, confusion
Physical Exam: Ataxia, angular cheilitis, glossitis (usually a late sign), dementia like symptoms (uncommon), positive Romberg test, pallor, petechiae, decreased sensation to vibration
Labs: B12 low, elevated mcv, low hematocrit, low reticulocyte count
Differential Dx: Diabetic Neuropathy, Stroke, Dementia, Hypothyroidism, Pernicious Anemia…. (these are just a few)
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