HY lecture notes:
82F + tea/toast diet for six months + high MCV; B9 or B12 deficiency? –> answer = B9 deficiency –> folate stores deplete in about six months.
“Tea and toast” diet was classically taught to us in 7th grade as synonymous with vitamin C deficiency, but on the FM shelf, they want B9 deficiency in an elderly patient with poor diet for six months. If the vignette wants vitamin C deficiency, they’ll say the patient “looks ill” (vague, but they say that) and has easy bruising, or bleeding from the gums or around hair follicles (perifollicular hemorrhages).
22F + vegan + high MCV + has Hashimoto thyroiditis; cause of B12 deficiency? –> potentially pernicious anemia (autoimmune diseases go together; this one is HLA-DR5) –> answer = check Abs to intrinsic factor / parietal cells. If they don’t mention autoimmune disease, answer would clearly be dietary deficiency from the veganism.
35M on phenytoin for epilepsy + high MCV; Dx? –> folate deficiency –> anti-epileptics (phenytoin, valproic acid, carbamazepine) all cause folate deficiency.
40M + large tongue + angular cheilitis + high MCV + serum methylmalonyl-CoA is not elevated; Dx? –> folate deficiency –> serum methylmalonyl-CoA is elevated in B12 deficiency but not folate deficiency.
Vegan + Q asks for nutrient deficiency + B12 isn’t listed; answer = calcium –> sounds obvious when you consider that vegans don’t eat dairy or fish, but this Q gets a lot of people. Students frequently and erroneously select folate as the answer here, but folate found in high amounts of dark green, leafy vegetables.
Point tenderness over a vertebra in older woman –> osteoporosis (compression fracture).
Point tenderness over a vertebra in younger patient on steroids –> osteoporosis (compression fracture).
Point tenderness over a vertebra in patient with autoimmune disease –> recognize patient is on steroids –> osteoporosis (compression fracture).
34F + Hx of SLE (or IBD, or RA, etc.) managed with multiple medications + point tenderness over vertebra; Dx? –> osteoporosis (compression fracture) –> need to be able to infer she’s on prednisone.
Point tenderness over vertebra + patient who has pituitary adenoma; Dx for adenoma? –> ACTH (Cushing disease) –> osteoporosis.
Point tenderness over a vertebra in IV drug user –> epidural abscess.
“Step-off” of one vertebra relative to another –> spondylolisthesis.
Back pain worse when standing or walking for long periods of time –> lumbar spinal stenosis.
