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Heme 2: Anemia 2: Vitamin B12 deficiency, folic acid deficiency, aplastic anemia Flashcards

5179880851	Macrocytic anemia		0
5179916977	Reticulocyte count is an indication of the function of what?	bone marrow	1
5179920302	Reticulocytosis definition	immature RBC pushed out of bone marrow a few days early	2
5179923291	Mechanisms causing macrocytic anemia (large RBCs >100 MCV)	- Abnormalities in DNA metabolism - Shift to immature cells - Bone marrow disorder - Lipid abnormalities - Unknown mechanism	3
5179925928	Macrocytic anemia is defined by what value of MCV?	>100 fl	4
5179926786	Megaloblastic anemia is defined by what value of MCV?	>115 fl	5
5179926796	What are some common causes of macrocytic anemia?	- reticulocytosis - alcoholism - liver disease - hypothyroidism - medication effect - aplastic anemia	6
5179929723	What are some common causes of megaloblastic anemia?	- vitamin B12 deficiency - folic acid deficiency	7
5179937632	What is the most common anemia found in alcoholics?	Macrocytic anemia - 90% of alcoholics have MCV 100-110 fL	8
5180030323	Macrocytic anemia can be caused by the effect of what medication therapy?	combination antiretroviral therapy for HIV	9
5180041722	Myelodysplastic syndromes (MDS) is due to a problem with what?	bone marrow itself (myeloid = bone marrow, dysplasia = ineffective production of all blood cells)	10
5180043984	MDS results in what reticulocyte response?	inappropriately low reticulocyte response	11
5180044713	MDS causes what type of anemia	macrocytic anemia	12
5180123568	Aplastic anemia definition	Bone marrow can't produce any blood components - pancytopenia --- platelets, RBC, and WBC lines are low - it is a type of bone marrow failure, but not all bone marrow failure = aplastic anemia	13
5180131022	Aplastic anemia is due to an injury to:	*Pluripotent stem cell	14
5180131763	The mechanism of aplastic anemia is	injury to pluripotent stem cell -> impairs proliferation and differentiation ->*induces T-cell mediated autoimmune response - "idiopathic"	15
5180138901	Causes of aplastic anemia include what three categories?	Acquired autoimmune congenital	16
5180149794	Acquired causes of aplastic anemia	- radiation and chemotherapy - toxins (benzene, solvents, glue vapors) - viral infections (EBV, hepatitis, HIV, herpes) - drugs (carbamazepine, phenytoin, sulfonamides, chloramphenicol, indomethacin, methimazole, propylthiouracil, gold - immune disorders - pregnancy - *anorexia	17
5180150552	autoimmune causes of aplastic anemia	*idiopathic SLE	18
5180163759	congenital causes of aplastic anemia	- *Faconi anemia -- defect in DNA repair pathway - dyskeratosis congenita - defect in maintenance of hematopoietic stem cell telomere length maintanence	19
5180167401	Steps leading up to aplastic anemia:	1) inciting event 2) aberrant immune response 3) destruction of hematopoietic stem cells 4) clinical disease	20
5180176159	Clinical presentation of aplastic anemia	- weakness and fatigue - *cardiopulmonary compromise - progressive anemia - mucosal bleeding, skin bleeding, petechiae - infection: --- bacterial, sepsis, pneumonia, UTI --- invasive fungal infection (common cause of death)	21
5180180646	Most common presentations of aplastic anemia include:	- Recurrent infections d/t profound neutropenia - mucosal hemorrhage d/t thrombocytopenia - increased menstrual flow in premenopausal women	22
5180188472	Physical exam of aplastic anemia:	generally not helpful - should see pallor, petechiae, purpura - should NOT see: --- hepatosplenomegaly, lymphadenopathy, bone tenderness ^ these are associated with bone cancers. the cells are normal, just very low numbers so won't see hepatosplenomegaly (not recycling defective cells)	23
5180196413	Aplastic anemia lab studies	CBC: - PANCYTOPENIA, anemia can be severe Peripheral smear - RBCs normocytic, may be macrocytic - decreased or absent polychromatophilic RBCs - cellular elements -> reduced in number, morphology normal - abnormal cells are NOT present reticulocyte index/count decreased (d/t stem cell destruction --> decreased production of blood components)	24
5180216489	Aplastic anemia differential diagnosis criteria:	***PANCYTOPENIA withOUT prominent splenomegaly - if splenomegaly is present, probably not aplastic anemia	25
5180220605	Diagnostic criteria for moderate aplastic anemia:	- Bone marrow cellularity <30% - absence of severe pancytopenia - depression of at least two of three blood elements below normal	26
5180229473	Diagnostic criteria for SEVERE aplastic anemia (SAA):	- bone marrow biopsy showing <25% of normal cellularity OR - bone marrow biopsy showing <50% normal cellularity WITH --- <30% of the cells are hematopoietic (producing blood cells) AND --- at least two of the following are present (1) absolute reticulocyte count <40,000/microL (2) absolute neutrophil count (ANC) <500/microL (3) platelet count <20,000/microL	27
5180251211	Diagnostic criteria for very severe aplastic anemia (VSAA):	criteria for SAA are met with: - absolute neutrophil count (ANC) <200/micoL	28
5180276409	Essentials for diagnosis of Aplastic Anemia	- Pancytopenia - no abnormal hematopoietic cells in circulation or in bone marrow - hypocellular bone marrow	29
5180277861	Aplastic anemia treatment (general)	- treat specific congenital causes or MDS - treat underlying cause - manage cytopenias - infection treatment and prevention - therapy is stratified based on age and disease of severity	30
5180280992	Treatment of mild-moderate aplastic anemia	- supportive care -erythropoietic growth factors (epoetin or darbepoietin) - myeloid growth factors (filgrastim or sargramostim) - transfusions - antibiotics or antifungals for infection - monitor closely for improvement or decline	31
5180424443	Treatment of severe aplastic anemia	Allogenic hematopoietic stem cell transplant (HCT) (bone marrow transplant) - treatment of choice in children <20 y/o with HLA matched sibling/donor - Preferred treatment in adults 20-50 y/o with HLA matched donor Immunosuppressive therapy (IST) - adults >50 y/o or no HLA matched donor - consider in adults 20-50 y/o with severe comorbidities overall, if under 50, look at for bone marrow transplant (HCT), if over 50, consider immunsuppressive therapy	32
5180465211	Immunosuppressive therapy for severe aplastic anemia:	suggested regimen: horse antithymocyte globulin (ATG) plus cyclosporin A (CsA)	33
5180471623	Prognosis of aplastic anemia	untreated -> 70% 1 year mortality rate SAA = rapidly fatal if untreated survivability rates 80-90% if treated	34
5180480386	Faconi anemia is the most common cause of	congenital aplastic anemia	35
5180484001	Faconi anemia is due to	- autosomal recessive disorder - defect in DNA repair pathway	36
5180487307	Faconi anemia results in	severe congenital abnormalities, progressive bone marrow failure, and increased incidence of malignancies - 60% of children present with a physical abnormality --- Syndaptoli = digits fused, common sign	37
5180494381	Fanconi anemia management	supportive modalities - androgens (male sex hormone) and hematopoietic growth factors can achieve a transient improvement in hematopoietic fx	38
5180503306	The only treatment option that can restore normal hematopoiesis in pt with fanconi anemia is	allogeneic hematopoietic cell transplantation (HCT)	39
5180506628	Megaloblastic anemia include what types of deficiencies?	Vitamin B 12 and Folate deficiencies	40
5180508572	Megaloblastic anemia classic advanced case presents:	severe anemia macrocytic red cells with or w/o varying neurologic disturbances (seen in vit B12 deficiency, not in folate deficiency)	41
5180513137	Megaloblastic anemia has MCV of:	>110 fL	42
5180514284	Megaloblastic anemia RBCs present as	macroovalocytic (oval in shape)	43
5180548978	Neutrophils in megaloblastic anemia present as	hypersegmented (several nucleus segments in neutrophil [usually 3-4, hypersegmented = 6 or more])	44
5180517999	Bone marrow in megaloblastic anemia presents showing	- erythroid hyperplasia (excessive growth of immature RBCs) - megaloblastic morphology	45
5180527274	Most common cause of megaloblastic anemia are	- faulty preparation of foods (such as vegans, not enough vit B12 in diet) - folate deficiency in pregnancy	46
5180531494	Clinical history and symptoms of vitamin B12 deficiency	Unexplained neurologic signs and symptoms - dementia or weakness - sensory ataxia (loss of coordination) - paresthesia (pins and needles)	47
5180535011	Higher risk population of B12 and folate deficiency	- older adults - alcoholics - patients with malnutrition - bariatric surgery pts	48
5180536157	Lab findings in vitamin B12 and folate deficiency	- macroovalocytes (large oval cells) - MCV > 100 fL with or without anemia - hypersegmented neutrophils (several nucleus segments in neutrophil [usually 3-4, hypersegmented = 6 or more]) - pancytopenia of uncertain cause	49
5180613122	How long does the body store vitamin B12 (aka cobalamin, Cbl)?	~3 years, therefore if suffering from vit b12 deficiency, must be chronic or ongoing for a long time	50
5180618452	Vitamin B12 absoprtion process	Intrinsic factor (IF) produced by parietal cells in stomach -IF is required for absortion of B12 - vit B12 and IF complex is absorbed in the *terminal ileum	51
5198080827	Where is vitamin B12 and IF absorbed?	** terminal ileum	52
5180629245	vit B12 and Folic acid function in the body (3):	nucleic acid metabolism myelin synthesis Critical DNA synthesis & regulation - *** DNA synthesis of hematopoietic cells	53
5180635008	Causes of vitamin B12 deficiency	- dietary deficiency (rare) - inadequate intrinsic factor - pancreatic insufficiency - Ileal disease (crohn's) - competition for vitamin B12 in gut - medications that block absorption	54
5180644781	Pernicious anemia definition	autoimmune disease where antibodies destroy gastric parietal cells, and binds to and neutralizes IF	55
5180644782	How does pernicious anemia relate to vitamin B12 deficiency?	Vit B12 absorption requires IF, produced by gastric parietal cells. - pernicious anemia autoimmune dx destroys these needed components, thus decreasing Vit B12 absorption -> megaloblastic anemia, and neurologic symptoms	56
5180654522	Signs and symptoms of Vit B12 deficiency	- relative to severity of anemia - glossitis (soreness/inflammation of tongue) - vague GI disturbances - *NEUROLOGIC syndrome --- peripheral nerves affected first -> distal/peripheral paresthesia (pins/needles) --- difficulty with balance and proprioception (body awareness in space) --- altered cerebral fxn	57
5180668792	Physical exam of vit B12 deficiency:	- pale - mildly icteric or sallow (jaundice-like, yellow) - atrophic glossitis - neuro exam: decreased vibration, decreased position sensation (proprioception), memory disturbance	58
5180674074	Lab findings in vit B12 deficiency**	CBC: - Macrocytic anemia (can be severe) - HCT as low as 10-15% - MCV 110-114 fL - Megaloblastic picture - Pancytopenia (leukopenia and thrombocytopenia in severe cases - low reticulocyte index - serum B12 (cobalamin) level low (<170pg/ml)	59
5180690356	Schilling test, has limited value, but can be used to test for	testing what is causing vitamin B12 deficiency	60
5180708184	Schilling test steps	1) give pt radiolabeled B12 orally + intramuscular unlabeled B12 2) radiolabeled B12 will not be able to bind to liver cuz of saturation by IM B12 3) wait 24-48 hours and measure pts urine for radiolabeled B12 4) if increased radiolabeled B12 in urine, then this means it was ingested, metabolized, and absorbed in GI (normally absorbed, no pathology, therefore dietary deficiency) 5) if decreased radiolabeled B12 in urine, then absorption problem 6) give the patient radiolabeled B12 + intrinsic factor, and two things will happen, either increased in RL B12 or decreased in RL B12 in urine. 7) If increased, then RL B12 was absorbed in GI, and cause is pernicious anemia -> attacks parietal cells -> decrease IF 8) if decreased RL B12 in urine, then there is no dietary deficiency, and no intrinsic factor deficiency	61
5180745541	Essentials of Diagnosis for Vit B12 deficiency:	macrocytic anemia megaloblastic blood smear - (macro-ovalocytes and hypersegmented neutrophils) Low serum B12 level	62
5180749087	Treatment of vit B12 deficiency:	parenteral therapy: - vit B12 100mcg SC or IM - daily x1 week, then weekly x 1 month, then monthly for life oral therapy: - methylcoabalamin 1 mg daily - sublingual or oral indefinitely concurrent tx for folic acid deficiency: - folic acid 1 mg PO daily - treat for 1-4 months of vitamin B 12 replacement	63
5180759488	Expected response with vitamin B12 treatment	- immediate improved sense of well being - hypokalemia possible in first days of therapy - reticulocytosis 5-7 days - hypersegmented neutrophils disappear after 10-14 days - hematologic picture normalizes in 2 months - neurologic symptoms may persist --- only reversible if short duration (<6 months of vit B12 deficiency) CBC starts to turn around at 1-2 weeks, and normalizes at 2 months so do CBC at 1-2 weeks and at 2 months	64
5180777384	Folic acid (pterolymonoglutamic acid) is found where?	present in most fruits and vegetables	65
5180780515	Body stores how much of folic acid?	5 mg, which is equivalent to 2-3 months of regular body requirement	66
5180782786	Folic acid is absorbed where?	entire GI tract (duodenum and jejunum)	67
5180787977	Causes of folic acid deficiency	- MOST COMMON = Inadequate dietary intake - alcohol abuse - reduced absorption (rare) - increased requirement - excess loss - medications	68
5180797078	Alcohol abuse and folic acid deficiency:	- alcoholics have lower folic acid stores - decreased serum folate 2-4 days d/t impaired enterohepatic cycle -> inhibiting absorption	69
5180802439	Signs and symptoms of folic acid deficiency	- Relative to severity of anemia - Glossitis - vague GI disturbances - *NO NEUROLOGIC SYMPTOMS	70
5180806204	Physical exam of folic acid deficiency	- pale - mildly icteric or sallow (jaundice like) - atrophic glossitis - NEURO EXAM: NORMAL	71
5180808697	Lab findings of Folic Acid deficiency:	CBC: - macrocytic anemia - can be severe - Hct as low as 10-15% - MCV 110-140 fL - megaloblastic picture - pancytopenia (leukopenia and thrombocytopenia in severe cases) - low reticulocyte index - serum B12 (cobalamin) level NORMAL (>210 pg/ml) - RBC folic acid level low (<150 ng/ml)	72
5180834678	Essentials of diagnosis for Folic acid deficiency	Macrocytic anemia Megalobalstic blood smear - (macro-ovalocytes and hypersegmented neutrophils) reduced folic acid levels in red blood cells or serum normal vitamin B12 level	73
5180840272	Treatment of folic acid deficiency:	Folic acid 1 mg PO daily for 1-4 months or hematologic recovery - continue therapy if underlying condition cannot be eradicated (congenital hemolytic anemia)	74
5180843430	Expected response from treatment of folic acid deficiency:	- Rapid improvement with sense of wellbeing in 5-7 days - reticulocytosis in 5-7 days - normalization of hematologic abnormalities within 2 months - ENSURE no concomitant vitamin B12 deficiency	75
5180852989	Vitamin B12 and folate overview slide pg 41 notes print		76

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Iron Deficiency Anemia(Microcytic) & Macrocytic Anemia (B12, folate def) Flashcards

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5213546592	LOW	If RBCs are overhydrated the hematocrit is ______	0
5213548189	HIGH	If RBCs are dehydrated the hematocrit is _____	1
5213551319	MCV	If you have clumping of RBCs then CBC may show elevated _____	2
5213556533	RDW	If RBCs have a HIGH _____ value, it means the cells are NOT homogenous (some very large, some very low)	3
5213561514	MCH	How much Hb in the cell compared to surface volume of RBC; average concentration of Hb in cell	4
5213568232	Reticulocytes = immature RBCs	-immature, non-nucleated RBCs that contain mRNA and are increased when the marrow responds to stress -Elevation of this count indicates that RBCs are being destroyed or you're losing a lot of blood (causing increased production) -depressed count if marrow is not able to compensate with the anemia -normally 0.5-1.5% in adults	5
5213571268	nucleus of lymphocytes	RBCs should average the size of the _____	6
5213578873	fatigue	Most common symptom of iron deficiency anemia is	7
5213598281	REMEMBER:	Iron deficiency anemia is NOT a diagnosis itself... must identify underlying problem: -GI tract blood loss: H.pylori, peptic ulcer disease -colon polyps -small intestine, tiny BVs that bleed -cancer -GU bleeding (stool, urine)	8
5213609674	-iron deficiency -anemia of chronic disease/ACD (some) -thalassemias (dysfunction in globin synthesis) -lead poisoning -sideroblastic anemia (dysfunction in heme synthesis)	Microcytic Anemias	9
5213626216	ferritin (indicative of iron storage)	With iron deficiency anemia, you continue iron therapy until the ______ is normal	10
5219501323	anemia	insufficient RBC mass to deliver oxygen to peripheral tissues	11
5219549969	males = 13 females = 12	lower limit of Hb in adult males is ____ g/dl and for females it is ____ g/dl	12
5219553557	120 days	average RBC lifespan	13
5219553558	80-100 fl	average RBC volume (MCV)	14
5219585138	family history diet travel medications blood loss weight loss, fever	relevant anemia history	15
5219591004	Microcytosis / Microcytic anemia	________ = RBC MCV of <80 fl	16
5219596632	-iron deficiency -anemia of chronic disease (ACD) -alpha/beta thalassemia trait is important to consider esp in African Americans	Most likely causes of microcytic anemia	17
5219609829	GI tract = source of blood loss GI malignancy Menstrual blood loss	Common causes of iron deficiency	18
5219621740	-decreased iron intake (inadequate diet or malabsorption - gastric surgery, celiac disease, increased gastric pH, tannins in tea) -increased loss: GI/GU loss (gastritis, peptic ulcer disease, menstrual loss) -increased requirements: pregnancy, childhood	Iron Deficiency Anemia: etiology	19
5219648353	-symptoms of anemia -pica craving for peculiar food or non-food substances e.g. ices, dirt, chalk -restless legs -Koilonychia-spooning of nails -Dysphagia (difficulty swallowing), esophageal web (plummer- vinson or patterson-kelly Sx)- very rare	Clinical manifestations of Iron deficiency	20
5219708459	decrease serum iron & decrease in ferritin (storage iron)	Earliest signs of iron deficiency	21
5219552599	120 days	average RBC lifespan	22
5219738472	iron deficiency anemia	CBC findings of ______ -increase in RDW and platelets -decrease MCV, MCH, MCHC, RBC, Hb, Hct -retic count not increased -serum: low iron, low ferritin high TIBC	23
5219818296	total iron binding capacity (TIBC)	maximum amount of iron needed to saturate plasma or serum transferrin, transferrin receptor	24
5219825400	Hb and MCV	___ and ____ decreased levels can be seen in Stage 3 of iron deficiency anemia	25
5219860731	hypochromic & microcytic	Profound central pallor is found in _____ & ____ RBCs	26
5219868323	1. Treat UNDERLYING CAUSE 2. Oral Ferrous sulfate 200 mg of elemental iron gives maximal Hb regeneration; absorption impaired by milk, tea, cereals side effects- nausea, constipation/diarrhea, abdominal pain; dark stool	Treatment for Iron deficiency anemia	27
5219889683	parenteral iron if still fail to respond to therapy: question diagnosis, compliance, associated illness, ongoing blood loss and malabsorption	If intolerant to PO iron, non-compliant, or iron therapy is malabsorbed give ___ for iron deficiency anemia	28
5219906994	Hb (usually returns to normal after 2 months) retic	Symptomatic response to iron therapy treatment precedes increase in _____; ____ count increased after 5-10 days of Rx	29
5219939357	Macrocytic anemias	encompasses both megaloblastic and non-megaloblastic anemias MCV > 100 fl	30
5219956038	megaloblast	-refers to characteristic bone marrow RBC precursors with specific chromatin changes; impaired DNA synthesis -in macrocytic anemia	31
5219963068	Non-megaloblastic anemias	_______ anemias do NOT have impaired DNA synthesis and RBC precursors are normal -common causes: ETOH, liver disease, alcoholism,	32
5219970207	Megaloblastic anemia	Anemias caused by -folate deficiency OR -B12 deficiency characteristics: -pancytopenia (may be seen with B12 def.)	33
5219984905	Pancytopenia	When anemia, leukopenia and thrombocytopenia occur together	34
5220004223	folate def = occurs rapidly B12 def = takes years to develop	In megaloblastic anemia, _____ deficiency occurs rapidly; _____ deficiency takes years to develop	35
5220022042	Neurological changes Ineffective erythropoeisis	_______ changes in B12 deficiency may occur without anemia; reversal of changes with treatment is variable Ineffective _____ (destruction of red cells within the marrow may be seen in B12 def) = labs may be suggestive of hemolytic anemia... but....LOW retic count, because hemolysis is occuring within the bone barrow ..	36
5220046986	3-4 lobes	Neutrophils normally have _____ lobes	37
5220053476	megaloblastic anemia; typically B12 deficiency	Hypersegmented neutrophils (ex. 8 lobes) & macro-ovalocytes are characteristic of ...	38
5220058594	1- pernicious anemia 2- surgical (several years after total gastrectomy or resection of terminal ileum - site of B12 absorption - acid blocking drugs in the stomach) 3- Zollinger-Ellison syndrome (gastric acid inactivates pancreatic proteases which impairs B12 binding to IF in the ileum) 4-pancreatic exocrine deficiency 5- blind loop syndrome (stasis, colonizing bacteria bind cobalamin-B12) 6- Diphyllobothrium latum infestation (bind B12 and prevent absorption) 7-Dietary deficiency (very rare, vegans)	Causes of B12 (Cobalamin) Deficiency	39
5220119116	pernicious anemia	autoimmune disorder -associated with vitiligo, hypotheyroidism -failure of secretion of intrinsic factor (IF) - Antibody directed against IF or parietal cells) leading to B12 deficiency	40
5220167218	B12 deficiency	If see macrocytic anemia with MYELOPATHY & the following symptoms (neuropsychiatric features - subacute combined degeneration-affects posterior and lateral parts of spinal cord) think..... -->Posterior columns (ascending fibers) -sensory disturbances -incoordination (legs)/ ataxia -diminished vibration, position sense -->Lateral columns (descending fibers) -weakness, spasticity	41
5220189233	Blood test B12 deficient if .... elevated levels of homocysteine AND methyl-malonic acid (MMA) And possibly Anti-IF antibodies in cases of pernicious anemia	If B12 = <200 deficient >400 NOT deficient between 200-400.. do not know so order ___?	42
5220197647	Folate	____ deficiency will show elevated levels of homocysteine but NOT MMA	43
5220226217	B12	Prophylactic _____ therapy is given in patients with gastric bypass or ileal resection	44
5220236374	hypokalemia	_____ may occur early on in B12 deficiency Treatment in severe cases bc potassium is an intracellular ion - taken out as maturation proceeds- can occur when you're replacing cells	45
5220254393	FOLATE/ folic acid (only 3-4 month supply) main food source = plant & animal cooking = easily destroyed	Test results characteristic of ______ deficiency 1- low serum folate concentration (<2ng; reflects recent intake)- cheaper screening test 2- low serum RBC folate concentration (less sensitive to dietary effects) 3-elevated serum homocysteine level (ONLY)	46
5220265139	1- inadequate diet (MAJOR cause) - elderly, poverty, alcoholism 2- impaired absorption - non-/tropical sprue, other diseases of small intestine 3- increased requirements - pregnancy, chronic hemolytic anemias, exofiliative dermatitis (ex. psoriasis)	Folate deficiency causes	47
5220281743	folate prophylactic folate oral treatment given during pregnancy, prematurity, severe hemolytic anemia, dialysis	____ deficiency can lead to neural tube defects of fetus in pregnant women; but a lot of food is fortified with folate to avoid this (ex. cereals)	48

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vitamin B12 deficient anemia- continue Flashcards

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7771358153	vitamin B12 deficiency anemia is also called	pernicio8us	0
7771362960	b12 deficiency is what type of anemia	macrocytic anemia	1
7771367487	role of vit B12	required for DNA synthesis and metabolic reaction involving folic acid	2
7771373786	decrease of vit B12 leads to	anemia decreased myelin synthesis	3
7771386846	___ is necessary for the absorption of B12	intrinsic factor	4
7771388898	intrinsic factor is ________	glycoprotein produced by the parietal cells of the stomach	5
7771394861	cells affected by Vit B12 deficiency	-rapidly proliferating cells -bone marrow cells -GI epithelium -nervous system	6
7771406589	drug that decreases B12	-metformin -antiepilectic -chemotherapeutics -antibiotics	7
7771410450	B12 is stored in the _____	liver	8
7771434107	indication of Vit B12 amenia	-cobalamin deficiency -hyperhomocyst einemia -induced elevated MCV	9
7771814204	lab findings in vit B12 deficiency	-increased lactate dehydrogenase -increased bilirubin -elevated	10