A 66-year-old man has had 4 months of fatigue and generalized weakness. He also reports a sore tongue, numbness and tingling in both feet, and unsteadiness when walking in the dark. He has been vegetarian for 30 years and has taken metformin for type 2 diabetes for 12 years. He has no known allergies. On examination he is pale, has a smooth red tongue, and has decreased vibration sense and proprioception in both feet with a positive Romberg sign. Hemoglobin 98 g/L (130-170), MCV 112 fL (80-100), vitamin B12 90 pmol/L (>150), ferritin and folate are normal, eGFR 78 mL/min/1.73 m2.
| Heart rate | 96/min |
| Respiratory rate | 16/min |
| Temperature | 36.8 °C |
| O2 saturation | 97%, room air |
| Blood pressure | 138/78 mm Hg |
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