OSCE prep

Dizziness- ddx?

Meniere's disease, BPPV, arrhythmias, orthostatic hypotension, migraine, antihypertensive drugs, hypoglycemia, labrynthitis, DM, aortic stenosis

Cough- ddx?

Inhaled foreign body, respiratory tract infection, COPD (mucoid/purulent), TB (bloodstained), bronchiectasis (purulent), lung cancer (bloodstained), PE, asthma, post-nasal drip, GERD, drugs (ACEi), sarcoidosis, pulmonary fibrosis, COVID, flu

Chest pain- ddx?

MI, pericarditis, GERD, peptic ulcer disease, angina, pneumonia, pneumothorax, PE, fibromyalgia

Doodoo diarrhea- ddx?

infectious, IBS, diverticulosis/diverticulitis, IBD, Celiac, cancer, ischemic colitis, cystic fibrosis, hyperthyroidism, drugs (antibiotics, PPIs), anxiety

Epigastric pain- ddx?

gastritis, GERD, peptic ulcer disease, biliary colic, acute pancreatitis, esophagitis

Abdominal pain- ddx?

cholecystitis, cholangitis, hepatitis, cirrhosis, appendicitis, diverticulitis, kidney stone, pyelonephritis, gastroenteritis, SBO, LBO, perforation, IBD, colorectal cancer, ectopic PG, pancreatitis, intussusception,

Headache- ddx?

tension HA, migraine HA, cluster HA, trigeminal neuralgia, brain tumor, giant cell arteritis, meningitis, subarachnoid hemorrhage

Hematuria- ddx?

BPH, bladder cancer, kidney stone, uncomplicated UTI, post-infectious GN, rhabdomyolysis, pyelonephritis

Back pain- ddx?

compression fracture, cauda equina, herniated disc/lumbar radiculopathy, muscle strain, spinal stenosis, spondylolysis, ankylosis spondylitis, fibromyalgia, discitis, osteoarthritis, osteoporosis, aortic aneurysm,

Shoulder pain- ddx?

AC separation, rotator cuff tear, impingement syndrome

Wrist or elbow pain- ddx?

DeQuervain's tenosynovitis, carpal tunnel syndrome, medial or lateral epicondylitis

Knee pain- ddx?

patellar fracture, ACL tear, PCL tear, collateral ligament tear, meniscal tear, Osgood Schlatter, patellofemoral syndrome, patellar/quadriceps tendonitis

Joint pain and swelling- ddx?

osteoarthritis, Rheumatoid arthritis, reactive arthritis, gout, lupus, septic arthritis, psoriatic arthritis, Rheumatic fever

Dyspnea- ddx?

pneumothorax, pulmonary edema, PE, anaphylaxis, asthma, pneumonia, pleural effusion, lung tumor, COPD, anemia, arrhythmia, heart failure, cystic fibrosis

Ear pain- ddx?

otitis externa, AOM, chronic otitis media, mastoiditis, foreign body, tympanic membrane rupture, barotrauma,

Eye pain- ddx?

blepharitis, hordeolum, xanthelasma, foreign body, conjunctivitis, subconjunctival hemorrhage, corneal abrasion, angle-closure glaucoma

Oliguria- ddx?

dehydration (vomiting, diarrhea), burns, acute tubular necrosis, acute glomerulonephritis, acute interstitial nephritis

Palpitations- ddx?

caffeine, nicotine, hyperthyroidism, PVCs, PACs, AFib, SVT, WPW

Polyuria- ddx?

meds (diuretics), DM, diabetes insipidus

Syncope- ddx?

aortic stenosis, hypertrophic cardiomyopathy, vasovagal, orthostatic, SVT, sick sinus syndrome, heart block

Throat pain- ddx?

strep, viral pharyngitis, thyroiditis, mono

Fatigue- ddx?

mono, viral hepatitis, hypothyroidism, DM, Addison's disease, CHF, renal failure, cancer, TB, rheumatoid arthritis, polymyalgia rheumatica, lupus, Crohn's, MS, myasthenia gravis, depression, pregnancy, influenza, COVID, anxiety

Vaginal discharge- ddx?

Candidiasis, bacterial vaginosis, Trichomonas, cervicitis

Anemia- ddx?

iron deficiency, chronic disease, sickle cell, G6PD, pregnancy, alcoholism, B12 deficiency, folate deficiency

Influenza

Sx: abrupt/severe sx, cough, congestion, high fever, headache, myalgias, fatigue, +/- GI symptoms

Dx: rapid test

Tx: supportive, Tamiflu if <48hr

Sinusitis

Sx: facial pressure, purulent discharge, dental pain

Tx: Augmentin if >7d, doxy if PCN allergy

less than 7d= decongestants

Allergic rhinitis

Sx: itchy/watery eyes, no fever, +/- mild "drainage" cough, mild sore throat, seasonal pattern

Tx: antihistamines + intranasal steroids (Flonase) daily

Strep pharyngitis

Sx: sore throat, no cough, painful lymphadenopathy, fever, exudate

Dx: rapid test, throat culture

Tx: penicillin

Acute otitis media

Sx: ear pain, ear "fullness", decreased hearing, fever, usually accompanied by viral URI symptoms

PE: bulging, erythematous TM

Tx: observation for 72 hours, then amoxicillin

Infectious mononucleosis

Sx: prominent fatigue/malaise, posterior lymphadenopathy, splenomegaly, high fever, sore throat, rash with amoxicillin or ampicillin

Dx: elevated LFTs, elevated WBCs

Tx: supportive (NSAIDs and acetaminophen), no contact sports for 4 weeks

Pneumonia

Sx: productive cough w/ thick sputum, pleuritic chest pain, high fever, SOB, myalgias

PE: tachypnea, rales/crackles, rhonchi, tactile fremitus, dullness to percussion, egophony

Dx: CBC and CXR

Tx: amoxicillin + macrolide (3rd gen cephalosporin + macrolide if PCN allergy)

Acute bronchitis

Sx: cough x1-3 weeks (viral) OR >3 weeks (bacterial), low-grade fever, dyspnea

PE: inspiratory wheeze, normal expiratory phase

Dx: no findings on CXR

Tx: supportive if viral, macrolide abx if bacterial

COPD

Sx: chronic cough, SOB, wheezing, dyspnea on exertion

PFTs: FEV1/FVC ratio <70%; hyperinflation; no recovery w/ bronchodilator

PE: increased AP diameter, decreased breath sounds, hyperresonance, crackles, rhonchi, wheezing

CXR: hyperinflation

Tx: LAMA/LABA + SABA/SAMA PRN

Treatment for COPD exacerbations?

SABA + SAMA + oral prednisone + antibiotics, continue LAMA/LABA

Asthma

Sx: dyspnea, wheezing, cough (often worse at night)

Triggers: exercise, illness, smoke, GERD, animals

PE: tachypnea, prolonged expiratory phase, low O2 sat

PFTs: decreased FEV1/FVC ratio, peak expiratory flow <80%

Tx: mild intermittent- albuterol, mild persistent- albuterol + ICS (fluticasone, budesonide)

Heart failure

Left: pulmonary edema (usually bilateral), dyspnea; rales, rhonchi, wheezing; orthopnea, S3 gallop, PND, fatigue

Right: ascites, peripheral edema, JVD, exertional dyspnea, hepatomegaly, N/V

Dx: CMP, BNP, LFTs, CXR, echo

Tx: diuretic + ACEi + beta blocker

Vasospastic angina

Sx: chest pain at rest, not exertional and not relieved by rest (typically occurs between midnight and 8AM due to decreased vagal tone)

Dx: transient ST elevations that resolve w/ symptom resolution

Tx: CCB and nitroglycerin (aspirin + statin if needed)

Stable angina

Sx: substernal pressure that radiates to jaw, left arm, back or epigastrum; diaphoresis, GI upset, cough, syncope; reproducible w/ increased HR; resolution w/ rest and/or nitroglycerin

Dx: normal +/- ST depression during pain event

Tx: nitroglycerin PRN, metoprolol, aspirin, atorvastatin

Refer for stress testing and coronary angiography

Irritable bowel syndrome

Sx: lower abdominal pain, cramping pain that comes and goes, pain is relieved or exacerbated by defecation, no nocturnal diarrhea

Tx: low FODMAP diet, laxatives for constipation, anti-diarrheals for diarrhea, CBT for psychological symptoms

Diverticulitis

Sx: severe LLQ pain with diarrhea or constipation, N/V, urinary symptoms, fever, hypotension, peritonitis signs

Dx: leukocytosis

Tx: metronidazole + cipro/levo for 2 weeks, clear liquid diet, bed rest

Crohn's disease

Sx: watery/mucosy diarrhea, crampy RLQ pain, and weight loss

Colonoscopy: segmental "skip lesions" and cobblestoning of mucosa

Biopsy: transmural inflammation and noncaseating granulomas

Tx: steroids and anti-TNF drugs

Ulcerative colitis

Sx: diarrhea that's occasionally bloody, crampy LLQ abdominal pain, and tenesmus

Colonoscopy: thin colon walls w/ continuous inflammation

Biopsy: no granulomas

Tx: topical or oral mesalamines, moderate/severe- steroids, biologics (anti-TNF drugs) and/or immunomodulators (MTX, azathioprine), curative surgery eventually

GERD

Sx: frequent heartburn, belching, regurgitation, cough after eating; worse w/ alcohol, spicy foods, coffee, eating right before bedtime

Tx: 1. lifestyle modifications, antacids, 2. H2 receptor antagonists, 3. PPIs (if >2 episodes/week)

Peptic ulcer disease

Sx: burning, gnawing epigastric pain, upper GI bleeding may be first symptom

Duodenal: pain relieved by food, antacids

Gastric: pain exacerbated by food

Causes: NSAIDs, H. pylori, smoking

Dx: upper endoscopy, urea breath test

Tx: PPI or H2 blocker

If H. pylori (+)= PPI + metronidazole + tetracyclilne + bismuth

Acute pancreatitis

Sx: constant severe epigastric pain that radiates to back, worsens when supine, relieved when leaning forward; nausea, vomiting, fever, and chills

PE: epigastric tenderness, dyspnea, shallow respirations, tachycardia

Labs: elevated lipase and amylase, elevated WBCs, elevated LFTs

Tx: IV fluids, pain control

Cholecystitis

Sx: RUQ and epigastric pain that radiates to R scapula and shoulder area, worse after fatty foods, nausea, vomiting, fever, chills

PE: RUQ tenderness, + Murphy's sign, + Boas sign

US: gallstones, gallbladder wall thickening

Tx: cholecystectomy, supportive (IV fluids, pain control)

Cholangitis

Sx: fever/chills, RUQ pain, jaundice (+/- altered mental status)

Labs: ↑WBC, ↑AST/ALT, ↑GGT, ↑bilirubin, ↑alk phos

Tx: IV antibiotics and ERCP

Hepatitis A

Sx: RUQ pain, jaundice, flu-like symptoms, dark urine, pale stools, prodrome- malaise, arthralgia, fatigue, anorexia, N/V, URI symptoms, fever

Labs: elevated LFTs

Tx: supportive

Appendicitis

Sx: periumbilical to RUQ pain, N/V, can't extend hip

PE: rebound tenderness, point tenderness, rigidity, guarding, (+)Rovsing, (+)Obturator, (+)Psoas

Tx: appendectomy

Kidney stone (nephrolithiasis)

Sx: renal colic (sudden unilateral, intermittent back or flank pain, unable to sit still), voiding symptoms, hematuria, N/V

Risks: PG, decreased fluid intake, hyperparathyroidism, DM

PE: flank tenderness, CVA tenderness, no peritoneal signs

Dx: non-contrast CT

Tx: NSAIDs (Toradol) and fluids, Tamsulosin, strain urine

Pyelonephritis

Sx: dysuria, polyuria, hematuria, fever, chills, tachycardia, back/flank pain, N/V

PE: CVA tenderness

UA: WBCs, nitrates, leukocyte esterase

Tx: 1. ciprofloxacin or levofloxacin, 2. TMP-SMX, hydrate

Uncomplicated UTI

Sx: dysuria, hematuria, increase in urinary frequency and urgency

PE: suprapubic pain and tenderness

Dx: UA- cloudy urine with presence of pyuria, bacteriuria, hematuria, leukocyte esterase and nitrites

Tx: TMP-SMX, Nitrofurantoin, or Fosfomycin

Bowel obstruction

Sx: severe, colicky abdominal pain, distention, vomiting, and inability to pass stool

PE: high-pitched tinkles on auscultation

Tx: relieve pressure via NG tube, supportive- IV fluids, pain control, antiemetics, bowel rest, surgery if not improving or recurrent

Tension headache

Sx: tight, band-like, constant pain; bilateral; MC in afternoon; not worse with activity, no N/V or aural symptoms

Tx: NSAIDs or acetaminophen for episodic, amitriptyline for chronic

Migraine headache

Sx: pulsing, throbbing, unilateral HA lasting >4hr; triggered by physical activity, stress, insomnia; auras subside before HA starts; N/V, disabling

Tx: eliminate triggers, NSAIDs or triptans

Prevention: if ≥2-3x/month= BBs or CCBs

Cluster headache

Sx: severe and sudden onset, piercing pain that rapidly worsens; unilateral, periorbital/temporal; same time each day; nasal congestion, conjunctivitis, lacrimation, diaphoresis; worse at night and with EtOH

PE: ptosis of eyelid, miosis, loss of sweating on face, conjunctival injection

MRI all suspected cluster patients

Tx: oxygen and sumatriptan

Prophylaxis: verapamil

Trigeminal neuralgia

Sx: brief, piercing, extreme pain; stabbing, shocking, "live wire" pain → very severe and can be disabling; unilateral near mouth → eye, ear, nostril; worse w/ light touch and vibration- breeze, kiss, shaving, chewing, washing, talking but NOT firm pressure

PE: normal except for eliciting pain w/ soft touch

Tx: carbamazepine

Giant cell arteritis

Sx: persistent HA, scalp tenderness, jaw pain while chewing, visual changes, fever, weight loss, fatigue, bounding or absent temporal artery pulses

Labs: ↑ESR, ↑CRP

Dx with temporal artery biopsy

Tx: HD corticosteroids

Type 1 diabetes

Sx: weight loss, blurry vision, polyuria, polydipsia, polyphagia, nocturia, recurrent UTIs

Dx: A1c >6.5% or FBC >126

Tx: insulin (long acting and basal)

Type 2 diabetes

Sx: MC asymptomatic, overweight/obese, blurry vision, nocturia, polydipsia, polyphagia, polyuria, recurrent UTIs

PE: may see acanthosis nigricans, diabetic retinopathy, renal disease, peripheral neuropathy, pruritis

Dx: A1c >6.5% or FBC >126

Tx: metformin to start

Benign prostatic hyperplasia

Sx: increased urinary frequency, urgency, nocturia, hesitancy, weak or intermittent stream, incomplete emptying, dribbling

Dx: DRE- uniformly large, firm, nontender, rubbery prostate; UA- R/O UTI

Tx: tamsulosin + finasteride

Rhabdomyolysis

Sx: dark brown/reddish urine, myalgias, fatigue, nausea, swelling of extremities; recent vigorous exercise, crush injury or statin use

PE: diffuse tenderness to extremities

Labs: UA + microscopy- hematuria but no RBCs on microscopy, ↑CK, ↑LFTs

Tx: fluids and pain control

Herniated disc/lumbar radiculopathy

Sx: unilateral back pain, may have paresthesias or numbness, may increase w/ coughing, straining, bending, sitting, squatting, Valsalva

PE: positive straight leg test

Tx: NSAIDs

Spinal stenosis

Sx: back pain, numbness, paresthesias that may radiate to butt, worse w/ extension (standing, walking upright), better w/ flexion (shopping cart position), doesn't worsen w/ Valsalva (distinguish between herniated disc)

Tx: NSAIDs, steroid injections

Rotator cuff tear

Sx: deltoid pain w/ decreased ROM, esp with overhead activities, external rotation, or abduction

Tests: empty can test, Hawkins test, drop arm test, Neer test

Tx: NSAIDs

DeQuervain's tenosynovitis

Sx: pain along radial aspect of wrist and base of thumb radiating to forearm especially w/ thumb extension or gripping, pain and tenderness at radial styloid

Dx: Finkelstein test

Tx: thumb spica splint, NSAIDs

Osgood Schlatter disease

Sx: activity-related anterior knee pain and swelling, relieved with rest, swelling and tenderness of anterior tibial tubercle

Tx: RICE, NSAIDs

Ligamentous injury special tests

ACL: Lachman test, anterior drawer test

PCL: posterior drawer test

LCL: varus stress test

MCL: valgus stress test

Osteoarthritis

Sx: joint pain, stiffness, worsens throughout day and with weather changes

PE: hard, bony joints; decreased ROM; crepitus; DIP and PIP enlargement

XR: asymmetric joint narrowing

Tx: NSAIDs or acetaminophen, duloxetine if multiple joint involvement or if NSAIDs are contraindicated, topical capsaicin

Rheumatoid arthritis

Sx: morning joint pain and stiffness >1hour, improves later in day; fever, fatigue, weight loss; usually affects small joints (wrist, MCP, PIP, MTP, spares DIP)

PE: symmetric inflamed joints (soft, boggy)

Labs: + Rheumatoid factor, anti-CCP, increased ESR and CRP

XR: symmetric joint space narrowing

Tx: DMARD (methotrexate) + NSAIDs

Gout

Sx: swelling of first MTP joint of great toe, joint pain, warmth, tenderness

Hx: purine-rich foods (alcohol, seafood), meds (thiazide and loop diuretics, ACEi, aspirin)

Dx: arthrocentesis- negatively birefringent, needle-shaped crystals

Tx: NSAIDs for acute attacks, allopurinol for chronic management

Lupus

Sx: joint pain, fever, butterfly malar rash, fatigue, night sweats, photosensitivity

Dx: ANA, anti-dsDNA and anti-Smith

Tx: sun avoidance, hydroxychloroquine +/- NSAIDs

Chlamydia

Sx: urethritis (purulent or mucopurulent discharge, pruritus, dysuria, dyspareunia), PID (abdominal pain, + cervical motion tenderness), reactive arthritis (uveitis, urethritis, arthritis)

Dx: urine NAAT

Tx: doxycycline (+ ceftriaxone to cover for possible gonorrhea)

Gonorrhea

Sx: urethritis and cervicitis- discharge, PID, epididymitis, prostatitis

Dx: urine NAAT test, UA- positive leukocyte esterase or pyuria

Tx: ceftriaxone (+ doxy to cover for possible chlamydia)

Herpes simplex

Sx: grouped vesicles on an erythematous base, prodromal symptoms before lesions appear (pruritus, burning, tingling, pain)

Dx: PCR, Tzanck smear

Tx: acyclovir or valacyclovir

Herpes zoster

Sx: prodrome of fever, malaise, sensory changes (pain, burning, paresthesias) followed by painful eruption of vesicles on erythematous base unilaterally within single dermatome

Dx: usually clinical, can use PCR and Tzanck smear

Tx: acyclovir, analgesics for pain

Education: no longer infectious once lesions crust over

Psoriasis

Sx: raised, well-demarcated, pink-red plaques or papules w/ thick silvery white scales on extensor surfaces of elbows and knees, usually pruritic, bleed when try to remove

Hx: may appear after strep pharyngitis, family history of autoimmune disorders

Tx: topical corticosteroids

Atopic dermatitis (eczema)

Sx: erythematous, ill-defined blisters, papules or plaques in flexor creases

Hx: family or personal history of eczema, allergic rhinitis, asthma

Tx: topical corticosteroids or antihistamines; maintain skin hydration (skin emollients twice daily), avoid triggers (heat, humidity) or irritants

Hypothyroidism

Sx: fatigue, sluggishness, depression, constipation, bradycardia, cold intolerance, weight gain, loss of outer 1/3 of eyebrows

Dx: high TSH, low free T4

Tx: levothyroxine - monitor TSH levels at 6 week intervals

Hyperthyroidism

Sx: palpitations, heat intolerance, tremors, weight loss, AFib, exopthalmos and pretibial myxedema (Graves)

Dx: low TSH, high free T4

Tx: radioactive iodine, propylthiouracil if PG

What are the only 2 causes of a painful thyroid?

subacute- sx of hyperthyroidism, follows a viral infection, tx w/ NSAIDs and acetaminophen

suppurative- bacterial infection, usually occurs in children, tx w/ antibiotics

Diabetic neuropathy

Sx: "stocking glove" paresthesias- involves distal lower extremities at first- loss of vibratory, proprioception, light touch, temperature; orthostatic hypotension, gastroparesis, carpal tunnel, cranial nerve palsies

Dx: neuro exam

Tx: glucose control, duloxetine or amitriptyline

Nephrotic syndrome

Sx: frothy urine, generalized edema (especially periorbital), fatigue, loss of appetite

Hx: recent viral illness, SLE, viral hepatitis

Dx: UA- proteinuria, hypoalbuminemia, hyperlipidemia

Tx: glucocorticoids, diuretics for edema reduction, ACEi for proteinuria reduction

Glomerulonephritis

Sx: coca-cola or tea-colored urine (hematuria), edema (peripheral and periorbital), fever, abdominal or flank pain, malaise, oliguria, hypertension

Hx: 10-14 days after strep infection (skin or throat), 24-48hr after URI or GI infection

Dx: UA- hematuria, RBC casts, proteinuria; CMP- increased BUN & Cr

Tx: ACEi for proteinuria reduction, diuretics for edema, BB or CCB for HTN

Prostatitis

Sx: irritative voiding symptoms- frequency, urgency, dysuria; obstructive symptoms- hesitancy, poor or interrupted stream, straining to void, incomplete emptying; fever, chills, perineal pain

Dx: DRE- boggy prostate (acute- tender and warm, chronic- nontender), UA- pyuria and bacteriuria

Tx: age >35= fluoroquinolones, age <35 or STI likely= ceftriaxone + doxycycline (cover for gonorrhea and chlamydia)

Benign essential tremor

Sx: occurs at rest, worsens w/ intentional movement, stress, anxiety; usually affects upper extremities and hands; improves w/ alcohol ingestion

PE: finger to nose testing

Hx: runs in families

Tx: propranolol if severe or situational

Myasthenia gravis

Sx: weakness that worsens w/ repeated muscle use and throughout the day, diplopia, ptosis, pupils are spared, weakness w/ prolonged chewing and dysphagia

Dx: ACh receptor antibodies

Tx: acetylcholinesterase inhibitors

Multiple sclerosis

Sx: sensory disturbances (pain, paresthesias), weakness (gait and balance problems), visual disturbances (diplopia, optic neuritis), fatigue

PE: spasticity, upward Babinski, hyperreflexia, muscle rigidity, positive Lhermitte's sign

Dx: MRI, LP

Tx: beta-interferon or glatiramer acetate

Depression

Sx: ≥5 for ≥2 weeks: sleep disturbances, loss of interests, guilt, lack of energy, concentration difficulties, appetite changes, psychomotor changes, suicidal ideation

Tx: SSRIs and CBT

Bipolar I disorder

Sx: at least 1 manic episode (>1 week)- distractability, impulsiveness, grandiosity, flight of ideas, activity increase, sleep deficit, talkativeness

Tx: lithium + atypical antipsychotic

Treatment for ADHD?

1. methylphenidate (Ritalin) or amphetamine/dextroamphetamine (Adderall)

2. atomoxetine

Schizophrenia

Sx: ≥2: hallucinations, delusions, disorganized speech, negative symptoms, disorganized or catatonic behavior for at least 6 months (≥1 must be hallucination, delusion or disorganized speech)

Tx: second generation antipsychotics- check for metabolic effects

PTSD

Sx: intrusion symptoms, re-experiencing, avoidance of associated stimuli, negative alterations in cognition and mood, arousal and reactivity symptoms

Tx: SSRIs, prazosin for sleep disturbances

Lyme disease

Sx: erythema migrans (bullseye rash), fatigue, HA, fever, malaise, arthralgias, AV block on EKG, facial nerve palsy

Dx: clinical if rash present and living/traveled to endemic area

Tx: doxycycline

Cellulitis

Sx: localized macular erythema (not sharply demarcated), swelling, warmth, tenderness

Tx: cephalexin, dicloxacillin

Lichen planus

Sx: purple, polygonal, planar, pruritic, papules or plaques w/ fine scales and irregular borders

Tx: topical corticosteroids

Chickenpox

Sx: fever, malaise, anorexia or pharyngitis followed by generalized vesicular rash- erythematous macules that become papules then vesicular then crust over, very pruritic

Dx: usually clinical, can use PCR or Tzanck smear

Tx: supportive (acetaminophen and calamine lotion) if under 12, acyclovir if over 12

Education: no longer contagious once lesions crust over

Iron deficiency anemia

Sx: fatigue, weakness, exercise intolerance, dyspnea, craving for ice, appetite for non-food things, koilonychia (spooning of nails), tachycardia, pallor, angular cheilitis

Dx: microcytic, hypochromic anemia; decreased ferritin, increased TIBC, decreased serum iron

Tx: iron replacement- educate about GI effects (N/V, constipation, dark stools)

B12 deficiency

Sx: fatigue, exercise intolerance, pallor, diarrhea, symmetric paresthesias, ataxia, weakness, vibratory and proprioception deficits, decreased DTRs, + Babinski

Dx: macrocytic anemia, decreased serum B12, increased homocysteine, increased methylmalonic acid (distinguishes from folate def)

Tx: IM B12 if symptomatic or neuro findings, oral B12 if dietary deficiency

Folate deficiency

Sx: fatigue, exercise intolerance, pallor, diarrhea, NO NEURO SX

Dx: macrocytic anemia, normal methylmalonic acid

Tx: oral folic acid