Station 45
Sarah Burkitt
Age: 32 years old female
Full Case
Patient’s Data
Patient’s name: Sarah Burkitt
Age: 32-year-old female
Past medical history
- Newly registered at the practice.
- History of vitamin B12 deficiency (noted in 2019 from previous GP records)
Drug and Allergy History
- Nil
Recent notes/ consultation
Seen 2 days ago by Dr Penelope Brinkman (Clinical practitioner access role)
Presenting Complaint: Patient reports been tired all the time. No red flags. Note previous B12 deficiency
Examination findings: BP 120/65mmHg, Pulse 68bpm, no lymphadenopathy noted.
Plan: Bloods, review with results
Results of patient’s bloods—yet to be filed
| Test | Result | Reference Range |
|---|---|---|
| HB (Hemoglobin) | 113 g/L | 120 – 170 g/L |
| MCV (Mean Cell Volume) | 105 fL | 80 – 100 fL |
| B12 | 94 ng/L | 180 – 1000 ng/L |
| Folate | 3 ng/L | > 7 ng/L |
Other Tests: Thyroid function test, Coeliac screen, U&Es, LFTs, HbA1c, CRP, and Vitamin D — all within normal range.
Note: Patient has booked a follow-up telephone consultation to discuss blood test results.
Patient's Story (Role player’s brief)
Patient’s Story
You are Sarah Burkitt, a 32-year-old woman, and you’ve booked this telephone consultation to discuss your recent blood test results.
You have been feeling tired all the time for the past 6 months, and it hasn’t improved.
You suspected that your vitamin B12 levels might be low, as you’ve had low B12 in the past and received B12 injections from your previous GP. Since registering with this practice, you’ve been managing with over-the-counter B12 and folate supplements (tablets), which you’ve been taking regularly for the past 5 months.
You’ve also made dietary changes, eating foods rich in B12 and folate, but you haven’t noticed any improvement. You are not on any prescribed medications, and you are not a vegan.
Your bowels and bladder are normal — no diarrhoea, constipation, vomiting, or bloating. You have no other symptoms to report.
You were adopted, so you do not know your family medical history.
If asked how the tiredness is affecting your life: You feel it is now starting to affect your work — you’re a medical secretary and are struggling to complete tasks on time. Despite this, you sleep well and your mood is not low.
Social History: You live with your partner, do not smoke or drink alcohol, and your menstrual cycles are normal.
Ideas: You think your B12 levels are low again.
Concerns: Your tiredness is now beginning to affect your job — you’re struggling to keep up with tasks.
Expectations: You want to discuss your blood test results and understand what’s going on.
If the doctor tells you that your B12 is low, you ask: “Why is it low even though I’ve been taking B12 tablets?”
If the doctor offers B12 injections: Ask: “How long would I need to be on the B12 injections? Is it something I’ll need for life?”
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about tiredness — whether it has changed or worsened since the last consultation with the colleague
- Ask about associated B12 deficiency symptoms: Memory problems or difficulty concentrating (possible cognitive changes from B12 deficiency), headache, blurred vision (possible optic neuropathy), mouth ulcers (e.g. angular cheilitis), tingling or numbness in hands/feet or other parts of the body (peripheral neuropathy due to B12 deficiency), palpitations, chest pain, or shortness of breath (anaemia-related symptoms)
- Ask about gastrointestinal symptoms that may suggest malabsorption — e.g. diarrhoea, bloating, vomiting (to consider underlying cause, especially as patient is taking oral supplements and B12 levels are still low)
- Ask about any personal or family history of autoimmune conditions (e.g. pernicious anaemia)
- Ask about dietary habits — whether the patient is vegan or vegetarian
- Ask how the tiredness is affecting her daily life (function, work, wellbeing)
- Ask social history, including smoking, alcohol, recreational drug use (especially nitrous oxide, which can inactivate B12) and occupation
- Ask about any prescribed medications (e.g. metformin, PPIs) not listed on patient’s note, or over-the-counter medications (e.g. OTC esomeprazole)
- Give a diagnosis of anaemia caused by B12 and folate deficiency.
Example of explanation to patient
Sarah, I’ve had a look at your blood results, and I think we’ve found a reason why you’ve been feeling so tired.
Your haemoglobin, which is the part of your blood that carries oxygen around your body, is a bit low — this is called anaemia. That could definitely explain your tiredness.
Now, we’ve also found that your vitamin B12 and folate levels are very low, and that’s likely the main reason your haemoglobin is low. B12 and folate are important vitamins that help your body make healthy red blood cells.
I know you’ve been taking supplements and eating well, so the fact that your levels are still low makes me wonder whether your body is struggling to absorb B12 from food or tablets. One possible cause is something called pernicious anaemia, where the immune system accidentally affects your stomach’s ability to absorb B12. If this is the case, you might need B12 injections instead of tablets, and possibly long term.
So, what we’ll do next is arrange a blood test to check for pernicious anaemia. This will help us find the exact cause and guide the best treatment.
In the meantime, because your B12 level is very low and you’re showing symptoms, I’d recommend we start you on B12 injections, which will be more effective than tablets as it seems the tablets aren’t working. The injections will usually be given three times a week for two weeks to begin with, and then we reassess. If we find a long-term absorption problem like pernicious anaemia, these may need to be continued regularly for life, but we’ll discuss that based on the results of your further tests.
We’ll start the folate treatment after the B12 course has begun, as it’s important not to treat folate alone when B12 is very low.
I’ll also arrange follow-up blood tests about 7–10 days after starting the injections, to check that your blood count is improving, and again after 8 weeks, to monitor your progress.
You mentioned it’s affecting your work, and I completely understand that. If you need, I can provide a fit note or amended duties note for your employer while we begin treatment.
Lastly, if you notice any new symptoms like tingling in your hands or feet, balance problems, or changes in your memory or mood, please seek urgent medical advice — these can be signs that the nerves are being affected.
Management
Management
- Offer a blood test for intrinsic factor antibodies to assess for pernicious anaemia. If this is normal, refer to gastroenterology for further tests such as a gastroscopy and colonoscopy to check for gut-related causes of malabsorption. If those are also normal, refer to haematology for further specialist evaluation.
- Start treatment with Vitamin B12 (Hydroxocobalamin) injections at a dose of 1 mg intramuscularly three times a week for 2 weeks. Folate replacement can be initiated after B12 treatment has started, typically 24 to 48 hours later.
- Arrange a full blood count and reticulocyte count within 7–10 days of starting treatment to check for response and repeat again after 8 weeks to confirm ongoing improvement.
- Explain that if no reversible cause is found, treatment with B12 injections may be lifelong.
- Advise she should continue eating food rich in b12 and folate.
- Offer a Fit Note with amended duties or workplace adjustments, as the patient’s symptoms are currently impacting their ability to work
- Safety net and advise the patient to seek urgent medical attention if they develop new symptoms such as tingling in the hands or feet, balance problems, or changes in memory or mood, as these may indicate nerve involvement.
Learning point from this station:
Deficiency of vitamin B12 or folate is the most common cause of megaloblastic anaemia. In the UK, pernicious anaemia is the leading cause of severe B12 deficiency. Other causes include:
- Drugs (e.g. metformin, colchicine, proton pump inhibitors)
- Intestinal causes (e.g. malabsorption, ileal resection, Crohn’s disease)
- Nutritional causes (e.g. malnutrition, vegan diet)
When a patient continues to have low B12 levels despite taking oral supplements, this should raise suspicion of malabsorptionas the underlying issue.
It is essential during history-taking to ask about possible neurological complications such as ataxia, paraesthesia, visual changes (e.g. optic neuropathy), and cognitive decline or loss of physical drive. If any of these are present, urgent specialist advice from a neurologist and/or haematologist should be sought.
If immediate specialist input is unavailable, treatment should begin with hydroxocobalamin 1 mg intramuscularly on alternate days until there is no further improvement, then switch to 1 mg every 2 months for maintenance.
When both B12 and folate deficiencies are present, B12 should be started first. Folate can usually be added 24–48 hours after B12 replacement has begun, to avoid the risk of worsening or unmasking neurological complications.