A 63-year-old woman goes to her general practitioner, complaining of extreme tiredness. She has been increasingly fatigued over the past year, but in recent weeks she has become breathless on exertion and light-headed and complained of headaches. Her feet have become numb, and she has started to become unsteady on her feet. PMH: None Examination: Her conjunctivae are pale, and sclerae are yellow. Her temperature is 37.8°C. Her pulse rate is 96/min and regular, and blood pressure is 142/72 mmHg.
Examination of her cardiovascular, respiratory and abdominal systems is normal. She has a symmetrical distal weakness affecting her arms and legs. Knee and ankle jerks are absent, and she has extensor plantar responses. She has sensory loss in a glove-and-stocking distribution with a particularly severe loss of joint position sense. Hemoglobin: 4.2 g/dL Mean corpuscular volume (MCV): 112 fL White…
