gastrointestinal disorders/gastric bypass

Lab Parameter	Value	Reference Range
Blood Glucose (during symptomatic episode)	2.5 mmol/L	4.0-11.0 mmol/L
Hemoglobin	14.5 g/dL	13.5-17.5 g/dL
White Blood Cell Count	7.2 x 10^9/L	4.0-11.0 x 10^9/L
Sodium	140 mmol/L	135-145 mmol/L
Potassium	4.1 mmol/L	3.5-5.0 mmol/L
Urinalysis	Normal	Normal

Lab Parameter

Value

Reference Range

Blood Glucose (during symptomatic episode)

2.5 mmol/L

4.0-11.0 mmol/L

Hemoglobin

14.5 g/dL

13.5-17.5 g/dL

White Blood Cell Count

7.2 x 10^9/L

4.0-11.0 x 10^9/L

Sodium

140 mmol/L

135-145 mmol/L

Potassium

4.1 mmol/L

3.5-5.0 mmol/L

Urinalysis

Normal

See Explanation

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Question 2 / 2

683d163ec1b3f4bd827dacf0

Surgery

gastrointestinal disorders

gastric bypass

Case History

A 48-year-old female presents to the outpatient bariatric surgery follow-up clinic 2.5 years after undergoing Roux-en-Y gastric bypass. She reports increasing fatigue, difficulty concentrating, and persistent paresthesias in her distal extremities, describing a "pins and needles" sensation. She also complains of a sore, smooth tongue and unsteadiness when walking, noting she often feels she needs to watch her feet. Her husband mentions she seems more irritable and forgetful lately. She admits to inconsistent adherence with her prescribed vitamin regimen, often skipping her daily multivitamin and rarely taking any additional specific supplements, citing cost and feeling "fine" for the first year. Physical examination reveals diminished vibratory sensation in her feet, a a positive Romberg sign, and a wide-based, somewhat unsteady gait. Given her history and current presentation, what is the most likely diagnosis and the most appropriate initial management strategy?

Lab Parameter	Value	Reference Range
Hemoglobin	10.2 g/dL	12-16 g/dL
MCV	115 fL	80-100 fL
Serum Vitamin B12	120 pg/mL	200-900 pg/mL
Methylmalonic Acid (MMA)	0.80 µmol/L	0.07-0.27 µmol/L
Homocysteine	45 µmol/L	5-15 µmol/L

A ) Iron Deficiency Anemia; Initiate oral ferrous sulfate 325 mg daily and recheck CBC in 3 months.

B ) Vitamin B12 Deficiency; Initiate intramuscular cyanocobalamin 1000 mcg monthly and counsel on lifelong supplementation.

C ) Folate Deficiency; Prescribe high-dose oral folic acid 1 mg daily and evaluate for celiac disease.

D ) Copper Deficiency; Order serum copper and ceruloplasmin levels and consider intravenous copper replacement.

E ) Vitamin B12 Deficiency; Initiate high-dose oral cyanocobalamin 1000-2000 mcg daily and monitor neurological symptoms closely.

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