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A 72-year-old gentleman is brought to your office because a home health nurse noted he was becoming progressively weaker and more fatigued. The patient was widowed approximately 9 months ago and now lives alone. He has a history of celiac disease for which he follows a strict gluten-free diet, but he has not been eating well. He also has a history of a seizure disorder and takes phenytoin. He takes no other medications. He has a history of alcohol abuse but states he has not consumed alcohol for many years; he does not smoke. His review of systems is positive for dyspnea on exertion and mild anorexia. He has no other symptoms.
Physical exam reveals a thin, pale-appearing man with normal vital signs. His conjunctivae are pale and his tongue is smooth, with moist mucosa and no oropharyngeal lesions. The remainder of the exam is unremarkable.
A CBC reveals a WBC of 4,500/mm3, hemoglobin 9g/dl, hematocrit 28%, platelet count 140,000/mm3, MCV 102 fl, RDW 14, and B12 level 900 ng/L (normal).