QuestionSBA
QuestionChoice
This patient has a macrocytic anaemia that is likely multifactorial given her B12 deficiency, folate deficiency, history of alcohol use, and liver disease. She requires correction of her B12 and folate levels to help with her symptoms. B12 should be repleted before folic acid is administered due to the small risk of precipitating subacute combined degeneration of the spinal cord or worsening peripheral neuropathy.
10035972
a
Start B12 supplements
QuestionChoice
Macrocytosis and haematinic deficiencies are common in gastroenterology/hepatology settings. Unless the patient fails to respond to therapy or there are other concerns, a haematology referral is not warranted.
10035976
e
Refer to haematology
QuestionChoice
This may be a useful step in the holistic management of her chronic liver disease, but is not the most appropriate next step.
10035975
d
Refer to dieticians
QuestionChoice
While the patient is anaemic, she has multifactorial macrocytic anaemia and normal ferritin levels. There is currently no evidence of iron deficiency. She should be prescribed vitamin B12, followed by folic acid.
10035974
c
Start iron supplements
QuestionChoice
This patient has a macrocytic anaemia that is likely multifactorial given her B12 deficiency, folate deficiency, history of alcohol use, and liver disease. She requires correction of her B12 and folate levels to help with her symptoms. B12 should be repleted before folic acid is administered due to the small risk of precipitating subacute combined degeneration of the spinal cord or worsening peripheral neuropathy.
10035973
b
Start folate supplements
Concept
Chapter
2693
6174
Macrocytic Anaemia
Topic
157
Haematology
19598
Macrocytic anaemia in patients with alcohol-related liver disease often indicates deficiencies in vitamin B12 and folate, necessitating appropriate supplementation.
A 43-year-old female is seen in an outpatient clinic for a follow-up of her alcohol-related liver disease. She reports being abstinent from alcohol for three months and has not experienced any episodes of decompensation. However, she reports feeling tired all the time.

Examination of her gastrointestinal system is normal. Routine blood tests show:

|                |         |                   |
| -------------- | :-------: | --------------- |
| Haemoglobin    |        98 g/L   | (M) 130 - 170, (F) 115 - 155 |
| White Cell Count   |     4.3 x10<sup>9</sup>/L   | 3.0 - 10.0      |
| Platelets          |     72 x10<sup>9</sup>/L            | 150 - 400     |
| Mean Cell Volume (MCV)     | 112 fL                  | 80 - 96       |

|                    |    |                  |
| --------------------------- | :-------: | ------------------------------ |
| Serum Vitamin B12           | 50 ng/L            | 160 - 925              |
| Serum Folate                | 1.9 μg/L            | (3 - 15                 |
| Ferritin                    | 173 μg/L            | 12 - 200                  |

What is the most appropriate next step in management?
a