Skip to Main Content

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

Notice to the Reader: The case author provided suggested answers to the questions related to this case in Appendix D to give students an example of how case answers should be constructed.


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 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. Also, my tongue is always sore and swollen, almost like I burned it on a piece of hot pizza, making it really hard for me to eat or drink anything.”


Julie Kindred is a 45-year-old woman who presents to your outpatient clinic with her husband. She claims that her fatigue and lethargy have been going on for 10+ years but have been worsening over the last 4–5 months to the point that she always feels tired. Additionally, she claims that over the past 2–3 weeks her tongue has become extremely painful and swollen and that she struggles to eat. Her appetite has diminished because she tries to avoid eating anything that could worsen her pain, and she feels “fuller” more quickly than usual. On questioning, she also mentions a slight tingling and numbness in her feet that seems to worsen when finishing any physical activity. The patient has lost about 10 lb over the past 3 months and states that she feels like she is running a constant low-grade fever.


Type 2 diabetes mellitus




Father alive (65 years old) with CAD, HTN, glaucoma, and type 2 DM;

Mother alive (64 years old) with HTN and asthma


Married for 12 years, lives with her husband; has two children (one son and one daughter) who are both healthy; (+) tobacco, 1 ppd since age 24; (–) alcohol, (–) illicit drugs; is an elementary school teacher with adequate health insurance


Albuterol (90 mcg/actuation) MDI two puffs Q 6 H PRN

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

Metformin 1000 mg PO Q 12 H

Omeprazole 20 mg PO daily



Pop-up div Successfully Displayed

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