Skip to Main Content

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services ( for more information.


After completing this case study, the reader should be able to:

  • Recognize signs, symptoms, and laboratory abnormalities associated with vitamin B12 deficiency anemia.

  • Select an appropriate dosage regimen for treatment of anemia resulting from vitamin B12 deficiency.

  • Describe monitoring parameters for the initial and subsequent evaluations of patients with anemia caused by vitamin B12 deficiency.

  • Educate patients about appropriate vitamin B12 therapy.


Chief Complaint

“I feel like I’m constantly tired and fatigued and my tongue is sore and swollen, making it extremely difficult for me to eat or drink anything.”


Aidan Joseph is a 65-year-old man who presents to your outpatient clinic with his wife. He claims that his fatigue and lethargy have been going on for years but have been worsening over the last 4–5 months to the point that he always feels tired. Additionally, he claims that over the last 2–3 weeks his tongue has become extremely painful and swollen and that he struggles to eat. His appetite has diminished because he tries to avoid eating anything that could worsen his pain, and he feels “fuller” more quickly than usual. On questioning, he also mentions a slight tingling and numbness in his feet that seems to worsen when finishing any physical activity. The patient has lost about 10 lb over the last 3 months, and he states that he feels like he is running a constant low-grade fever. His wife adds that she feels that he is becoming more confused, and this has been worsening over the last several years.


  • COPD

  • Type 2 diabetes mellitus

  • Gout


  • Father alive (85 years old) with CAD, HTN, glaucoma, and type 2 DM

  • Mother deceased at age 75; had HTN, Alzheimer dementia, and CKD


Married for 42 years, lives with his wife; has two children (one son and one daughter) who are both healthy and live in the area; (+) tobacco, 1.5 ppd since age 24; (–) alcohol, (–) illicit drugs; is a retired pharmacist with good health insurance


  • Docusate sodium 100 mg PO Q 12 H

  • Albuterol MDI two puffs Q 6 H PRN

  • Fluticasone/salmeterol 250/50 one puff Q 12 H

  • Tiotropium 18 mcg one puff daily

  • Metformin 1000 mg PO Q 12 H

  • Glyburide 5 mg PO daily

  • Colchicine 0.6 mg PO daily

  • Allopurinol 300 mg PO daily


  • Penicillin (hives)

  • Levofloxacin (anaphylaxis)


Complains ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.