Barış Yurtsever

142001022

ALTINBAS UNIVERSITY FACULTY OF MEDICINE

INTERNAL MEDICINE ELECTIVE STAGE EXAM

GOOD LUCKS!

1. PLEASE, WRITE TO BELOW THE FREQUENTLY DETECTED THREE CAUSES OF VITAMIN B12
DEFICIENCY.
A) Impaired gastrointestinal absorption of vitamin B12 :
 atrophic gastritis (especially pernicious anemia)
 partial or total gastrectomy
 ileal resection or disease (such as Crohn disease, celiac disease, tuberculosis of intestine)
 long-term use of antacids, H2 receptor antagonists (H2RAs), or proton pump inhibitors (PPIs)
 use of proton pump inhibitors or histamine 2 receptor antagonists for ≥ 2 years each
associated with vitamin B12 deficiency
 chronic alcoholism
 pancreatic insufficiency (see also Chronic pancreatitis)
 bacterial overgrowth (for example, in blind loop syndrome)
 parasites (for example, giardiasis, fish tapeworm)
 Zollinger-Ellison syndrome
 Pernicious Anemia
 Smotach Ulcers
B) Decreased intake of vitamin B12 :
 malnutrition
 reduced intake of animal products
 strict vegan diet
C) Increased vitamin B12 requirements :
 hemolysis
 growth in children and adolescents
 pregnancy

2. HOW DO YOU TREAT VITAMIN B12 DEFICIENCY?

 Vitamin B12 replacement therapy with cyanocobalamin or hydroxocobalamin is usual first-line

treatment for vitamin B12 deficiency.
 Cyanocobalamin may be given orally, intranasally, or by intramuscular or deep subcutaneous
injection. Cyanocobalamin 1,000 mcg/day intramuscularly or subcutaneously for 1-5 days, then
1,000-2,000 mcg/day orally.
 Barış Yurtsever
142001022

 Hydroxocobalamin may be given by intramuscular injection. Hydroxocobalamin 1,000 mcg

intramuscularly on alternate days until no further improvement.

3. PLEASE, WRITE TO BELOW THE FREQUENTLY DETECTED THREE CAUSES OF IRON

DEFICIENCY.?

 Blood loss: Malignancy, menstruation, trauma...

 A lack of iron in diet
 An inability to absorb iron:
1)Premucosal:
 Inadequate digestion: Postgastrectomy, chronic pancreatitis, Cystic fibrosis,
Pancreatic resection, Zollinger-Ellison syndrome
 Deficient bile salt: Obstructive jaundice, gall stone, terminal ileal resection
2)Mucosal:
 Primary mucosal abnormalities: Celiac disease, tropical sprue, Whipple’s disease,
amyloidosis, Giardiasis, H.pylori infection
 Inadequate absorption in small intestine: Crohn’s disease, intestinal resection,
jejunoileal bypass
3)Postmucosal:
 Lymphatic obstruction: Intestinal lymphangiectasia, malignant lymphomas,
macroglobulinemia

4. HOW DO YOU REPLACE THE IRON STORE?

 Identify and treat cause of blood loss (if due to menstruation, iron supplementation may be
sufficient treatment)
 Consider blood transfusion if hemoglobin < 7 g/dL or at higher level (< 10 g/dL) in patients with
severe symptoms or who cannot tolerate anemia (elderly, cardiorespiratory disease)
 Oral iron supplementation
 dosing (as elemental iron) for treatment of iron deficiency anemia 60-120
mg/day orally
 in pregnancy, may decrease to 30 mg/day when hemoglobin normal for stage of
gestation
 in patients > 80 years old, low-dose iron supplementation (elemental iron 15
mg/day) may be as effective as higher doses with fewer adverse effects
 Monitoring and duration of iron replacement treatment

 If inadequate response after 3 weeks consider nonadherence, blood loss, additional

complicating factors, or incorrect diagnosis
 Normal hemoglobin levels usually achieved in 2 months unless continued blood loss
 Continue iron therapy for about 6 months in severe deficiency

 IV iron supplementation

 Indicated for treatment of iron deficiency not amenable to oral iron therapy
 Barış Yurtsever
142001022

 IV iron dextran has been associated with life-threatening anaphylactic reactions,

immediate and delayed
 Sodium ferric gluconate or iron sucrose
 Increase dietary iron intake
 Iron rich foods include red meat, poultry, fish, beans, dark green vegetables, raisins,
apricots, prunes, and iron-fortified breads and cereals.
 Ascorbic acid may improve iron absorption from meals.