Jeffrey
Sall Pa holok, R.N. SN ergenc room nurs with eighte ye rs of xp ri nc re iv he bach lor' degr in nu sing from Wa ne Stat ni versit Prio to nterin th fi ld of nu sing sh received an ssociate egre di
nc
Su prov nd lo co unit coll ge in tr inin paramedics in CLS. Sh is Tr um ursing Core Course (TNCC) Provider an Emergenc Nurs Pediatri Course (ENPC) Provider nd me be of th merg nc urse ssociation EN ). In 1985 Pacholok di gnos hers lf it vitami 12 deficiency afte he oc ha di bo he pu bo qu hi an aU-too-commo disease. Jeffrey J.
ti
ge
.ce vanced Trauma Life Support Advanced Cardia Life Suppor (ACLS) Advanced Pediatri Li Support, an on ta esus it tion Stuart eceive hi Doctor pa om op hi ic training include fiel amputation an hazardou material decontamination an pa pa ns trop port SWAT·team.Dr. Stuart participated in visual brai research at th National nd ol holest ro tabolism research at th ockefell niversit Hospit in ew or City in 1985 is embe of th meri an st op thic As ociation th meri an ollege of st op thic Emergenc Ph icians th Ma om County Osteopathi Society, an th Michigan Osteopathi Association.
OU
I. Neurological Manifestations
Population
(+2 (+2) (+2) (+2) (+2) (+2) (+2) (+2) (+2) (+2) (+2) (+2) (+2) (+2)
paresthesia weakness (extremity dizziness, lightheadednes syncop fallin abnormal gait/ataxi enta tatu change confusion/disorientation dementia diminished proprioception distorte touch/pain perception impaired vibratio ense muscular spasticity tremor abin it (+2) paralysi (+ 1) incontinence (urinary/fecal) (+ I) impotence
ixty ea il is er ic ia (+2) atin isorders anorexia bule ia (+2) ga tric bypa (+1) hi tory of thyroi isorders autoimmune disorders (+1) histor ofIDDM (+ 1) histor of cancer chemotherapy or -radiation therap (+ i) ad inistratio nitrou oxid (+2) vegans or vegeta ians (+1) prescribed medications: (antacids, 'Hz-blockers potassiu chloride henytoin etfonnin proton pump inhibitors cholestyrarnine, colchicine
VI Disorder with Possible Underlying Cb Deficiency
Hematologic Manifestations Deficiency (+2) (+2 (+2) (+2) (+1) (+1) (+1 (+
anemia macrocytosis ovalocytes or eliptocyte neutrophil hypersegmentation anisocytosis leukopen thrombocytopeni microcytosis
III. Psychiatric Manifestations
(+2) depression (+2 hallucination (+2) delusion (+2) violen behavior (+2) personalit change (+2) psychosi (+2) apathy (+2) paranoia (+2 irritabilit (+2 schizophrenia Gastrointestinal Diseases (+2) gastri atroph (+2) hypochlorhydria/ac lorhydri (+2 gastritis. (+2) ulcers (+ inflam ator bo el diseas (+2 diverticulosi (+2) gastrointestinal neoplasm (+2) gastrointestinal resections (+2) malabsorptio syndrome (+2) smal bo el over rowt (+2) diphyllobothrium infectio (+2) Zollinger-Elliso syndrome (+2) pancreatic exocrine insufficienc (+2) Imerslund-Graesbec syndrome (+2) Croh 's di ease (regiona enteritis) (+2) Celiac diseas (glute enteropath
Cobalami
Lo
Deficiency Risk (CDR) Score
11Sk:les than
Ri
6,
(+2) (+2) (+2) ( +2 ) (+2 +2 (+2) (+2 (+2) (+2) (+2) (+2) +2 +1
Alzheimer' diseas multiple sclerosi peripheral neuropathies A l D S dementia complex hyperhomocysteinemi congestive hear ailure autism fibromyalgia patients on hemodialysis vertig Meniere' diseas infertility chroni fati ue yndrom histor occl sive ascula diso ders (TIA CVA, Ivil, PE VT (+1) thalas emia trai (+1) iron deficiency (+ 1) alcoholism (+ 1) polycythemia (+1) radiculopath from back disorder/injur (+ 1) ai ekin VII. Othe anifestation of Chi Deficiency (+ I) fatigue/lack of energy (+ 1) generalize weakness (+ I) weight lossllos of appetite (+1) constipation or diarrhea (+1) opti neuritis (+ 1) orthostati hypotensio (+1) ches pain/exertions dyspne (+1) hepatomegaly or splenomegaly (+ poor woun healing/ulcer/decubitus (+1) prematur grayin (+1) hyperpigmentatio (+1) pallo (+1) glossiti (+1) vitiligo (+ 1) cervical dysplasi " (S om e o f h es e d is or de rs /c on d o n ca diagnosed cw h r e y mp t m s c t d ef ic ie nc y O t he rs , s uc h a s h em od ia ly s s , r is k o f d e c i n cy , I n n um b he de ci nc ne ds he nv ga
h e m is ta ke nl y ll Bl c a c on tr ib u he c on d n s B " n de r y in g c a s e
COULD
IT BE Bl2?
su patients.)
making injected
2d 12lev-
I'
,I I-
byclE~~Gl~~~jfllIIfi:ro1s < s U P ' @ l 1 c r1 0
en
~'j~,
:- ,anoc0'5alal~ Wintrobe
ogy, "1:' -$t\1l~'i:et~ntri.:0,11l f h y a F o x G G Q " , b a l , a m i n three time
greater.
is bette' than tfbat
addition, J f t Y . 4 r , , ? ~ 0 § 0 b : a t ~ L m i n1 'SS\1ller~.aSv'roilabi€'rtoq
ciel"s~an··sr.PF~ee~ed mor
effie1enll
.le
st
172
Clinical Hematol-
in l2
IN ORMA IO
iolo .dose
ti rnethylc balami
re
result ih
ie
I.
PH SICI
th
;!
gr ater accumulation of co alamin
cobalamin.
.1
life. It
17
COULD
ve op
otoc
or ef
screening.
ef
~ost"'Etfective J i I i r l vial e f h y d ro x 0€ o ba l
iinelthatp:t:€scribir:Ig m'
well
mc ml wo
]€)f
patients seltf-administering
/.
will
nc expiration date. 86 degree
Fahrenhe t. Unfortunatelypharmaceutical ml vial of'hyd oxocobalamin
combu hi in ei-
ml
I,
An ob ig ti
pa n,
or al specia ti
kn
us ef en
ha
au
ar xa
health problems
term follow-up. ~ ~ H 2 c l - ' f € € l1 e ~ g " h ef ~~ - = i t , C a N s e
is
problem d r a _ sNouHd Theident~fieillraF1'~r s ym p o m
seFlolls B1
174
6N@Ngh
ef
·t@·.retqf[1Feeinumgeae-Y' el ps ow an
COULD
IT BE
12
12
bord line or lo potassiu
levels houl re eive po assium supple
be or th rapy is initiated, to prot
with
12 therapy. Therefore, seru
st nd rd inje tabl
regi
in
gainst rrhyth ia
potassiu
pati nt
it
some
12
in.. Bl2
1-70
drop
nt
empo ry drop
levels an th plateletcoun
12
ileum. It
conc ntration
;S 12
N FO R 1
F O R PHYSICIANS
AT ON
c ru c a l o l
BI2'S
the fu'll;.
.0
s' em fnilff
12
nt
lCf~e-ieln~M.,
un 12
he
levels could be responsibl
12
rang of neurologic he atologic im unologic reproductive function
..nu erou
includin
en mati
tabolic, vascular
nd
th following:
re ctions
St.€l-m, ~aiIftel'l1i!!!£~ al'lea1t1n.rY.i\ne:r,;V€H1S VOliS
systems ic
d,
us
assist in converting th amin acid homocysteine (Hey into th no
hi
ta
12
is no present,
foli acid become "trapped" an canno fimction properly lead in to dangerousl
elevated levels of toxi homocysteine
12 -deficiency-relate
metabolism:
comple
problems
pathwa
111
ch as er ro
ac DV ),
aq ry rt (C ro
D) ),
ca ck
rt
ar IA
(M!),
...
mat ((II.
. J E l i k . l _ F l u r , z " Y B1'2
l{[fon
af
Ph Go ~«
V sao"fnit-oneql { C i F f e r - o ' p t h e . . 1 : J . ~;Pf1p.u~
in vitamin
ts
in
more
it
it
..
lt
12
,I
ib isabilit from
li ti
tr
is
ematologic or neuropsychiatric
ts
omplicatio s,
both."
Postgradu-
-T
at Medicine
th
te ts
CT scans,
ti
12
tested fo this comm n, simple-to-treat, an
otentially
defi-
eadl problem.
treat have symptoms 2'
i?e:ef1t¥th ~p@ l'Jul~?
However,
a~
·Qblen.ta1Jt¢'1ts.
li
m'~r'"
ci nc
12
ke 01:
pa
ha ca
on
pl cy
es
nd
al
with
Bl2
de ou
ed
gn ze
If
oc or
12
Neurological Symptoms If
points, 10H{
If
give yourself anothe po ntfo
each additional symptom.
opathy? ex
en
ht
dc
es
di zi es
AR Ya
AT RIs
FO
VITALVIIN
12
distorted? ac
es
on
on :;:.,-! :)
•'I
:>
2. Ps ch atri
If
"1
Sy ptom
points ..If 10H~
ve
ur el
ot er
dd
pt
.!
iI '1 r;'
ns an e,
ou
ds
ha
ou
"n
ng ke
,. (:1:
'.
I.'
sis
01: ,0
disorder? 'II·
people's action or intent on
· .. . . 1 .
b e l o w ; give y o u r s e l f twopoints.
If er po nt
ch
al ympt
B12?
mia? ount or lo
he oglobin)
normally larg (macrocytosis) 4.
astroint stin
If twopoints.
is
Factor
If
is symptom.
th
ng
ease (GERD) ou have diverticulosis Have ou been di gnosed growth
or ga troint stin
it pr an erou an er go
ou (Crohn
gast oint stinal
by
of disease, infl
toimmune disease) .Ha trointestinal parasite
matory bowe disease, irritabl bowe
:.
AR Yo
IS
IT
IN
:'
If yo
eneral
is
-.
actors
b e l o w . give yourself
on point.
et s, rheumatoid
rthritis Hashimot "s thyr iditis
ra es
in gammaglobulinemia, ther py
nder ne ra iation th ra y? lu in
rs (P pcid
ntac
agam t,
xi ),
tassiu
ta
hl ride (K.-
tr .losis?
If
Othe
ig s/ ympt ms lf
.w your kitchen)
color?
ften As ociate
with
12 Deficiency
COULD
12
ty
Calculate
Ad
nt
or
Moderate Risk: with
Ifyo
sc re
Your Score:
to
points
in 12
lev12
B12
and Ivllv1A levels checke
If Ib
12
ie iv
:M
is
to
e-t
12
150
deficiency:
la
INVISIBL
12
Commom
levels.
B]2
Deficiency?
12
below underestimate th pr valenc serum
EPIDEtvITC
of defi ienc
beoaus
levels. nearly
eighty-three
perc nt exhibite
12
levels in th "low normal range-
ne r-defi ienc
Re
rk bl
in 12
lo
erum
12
in th elderly. deficiency. B1
12
levels.e
an over SOp-ercent de-
3,4
12
is unique
.a
ge
ow
un
INVISIBLE EPIDEMIC
12
deficiency. 12
and does
12
ake- cyaf Ocobalam n, on
peci
or
of
l2
af 1.
B12
.Notes ud McBride,
12
ri ultura
," Rese rc Servic ebsite .S ep rt en http://www.ars.usda.gov/is/prI2000/
000802.htm. D.
3.
4.
el er admitted er atri sp ta gi g(20 1) 4Crane, M.G. Register U . D . Lukens,
re ry R. Cobalamin Vegetarian Nutrition;' An International J o u r n a l 1998,2(3):87-92. Bi oli, L. France co Ballar n, ., Mandra na R. Tr sp di R, ie on homocysteine 46(2):73-9.
6.
High 12 levels in Israel J o u r n a l of Nutrition, H e nd
evel
., an
N u tr i o n a n d M e ta bo l s m 2002,
Wwvv.emarcusdavis.com!practice/practice_lml0m.html
19
12'
12
12
augmente
with
supple ent, isn' sufficient fo many eo le 12
12
in
12 12
li
th
1,
12 12
t,
la
se 12
causin
dangerou
lo deficiencies
ts
le
ir li th
it
ti
